GW1-2021-07390_Well Construction - GW1_20210921

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Print Forme'.:
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4448A
ti -'1TO
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable
Cummings Developments, Inc FROM I TO I DIAMETER THICKNESS I MATERIAL
Company Name } I ft. 1 1!57t) ft. 1 (0 5'g in. . 18 g 5k
_ 16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit#: 31 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Pi Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ Itri Tation FROM TO MATERIAL EMPLACE NT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. -to
Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery E3 Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
I Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ® ft. ft. '
4.Date Well(s)Completed: `-2'1 Well ID# ft. L, ft. ! M G
5a.Well t CALocation:
/1 k
aa sb Y1
Facility/Owner Name
�Facility ID#(if applicable) ft. ft.
a�0 t�t'F O�C�Cyr [J0.Vi l yex 1CaI ��n1� ft. ft.
as
Physical Address,City,and Zip p, ft. ft.
T'I y�Ip �I k C I,4-tv'44Q / 21.REMARKS
County Parcel Identification No.(PIN) Pqmq
(11t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 3t10f)�r0
(if we`ll field,one IatlAong is sufficient) ? I 22.Certification' D
/ N �����-/S� W 6-19- Z'
6.Is(are)the well(s) Permanent or Temporary S' ture o ied Well Contractor Date
y signing this form,I hereby certify,that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or MNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iflhis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Jd (ft.) Division of Water Resources,Information Processing Unit,
If ware,•level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Iniectll n Wells' In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources! Revised 2-22-2016