GW1-2021-07407_Well Construction - GW1_20210921 (4)

Print Form
WELL CONSTRUCTION RECORD GW 1) For Internal Use Only:
I.Well Contractor Information:
Christopher Watcher
waxEl�<ZONESW: _
Well Contractor Name p S,�yO� FROM TO DESCRIPTION
4448A �� pt°��{oN ft. ft.
NC Well Contractor Conification Number "J RSA
\t��Oj�+ Q� 25 OIITER:CASING:far:mnitt casi6l wells:OR L,1NERti(If i3O cable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name +t ft. ft, a in. PVC
to
r:16:1INNERiGASIN
{W IyGOR ttIBING,`eottierm`at:etosed Ioo
2.Well Construction Permit#: Z o "' D NQ^ Pi FROM I TO DIAMIZMR I THICKNESS MATERIAL
List all applicable—11 constriction permits C.e UIC,County.State,Variance,etc.) _ ft. ft.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i 27::SCREEN(
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS AiATERtAL
En' E)Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) tr. ft, tit.
Industrial/Commercial 13Residentiai Water Supply(shared) LWGRO
_-
Irrigation FROM TO MATERIAL EMPLAC METHOB 8r AMOUNT
Non-Water Supply Well: O ft. ft,
Monitoring }Recovery tt. ft.
Injection Well:
Aquifer Recharge ft. ft.
q g QGroundwatcr Rcmediatian
Aquifer Storage and RecoveryFROM
TO PACK°M
�'SSlinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stointwater Drainage [t ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTtacer 20 IIRIGLING L••OG ittacti additionaU"sheets Iftineeessa "
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardy solFroca a rain Am.etc.)
�} �r ft. "� fL
4.Date Well(s)Completed: "sd`G Well ID# ft. Z2.0 ft.it
Sa.Well Location:
%
Facility/Owner Name Facility ID#(if applicable) ft. fL
*ft. ft.
Physics Address,City,and Zip ft, ft.
211 REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
of well field,one Iat/long is sufficient) 22.Certification:
?V00.ft I' N 7q°37,o W
6.Is(are)the well(s)OPermanent or 01remporo ry Si of C ell ContracWr Data
gn ng this form,1 hereby cent that the welts)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or RJNo whdr ISA NCAC 02C.OI00 or 1SA NCAC 02C.0200 if'el!Construction Standards and that a
If this is a repair,fill out known well construction informatlon 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 I GW I 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) 24s. For All Wells: Submit this form within 30 days of completion of well
For ondtip/e wells list all depth$ifd(Berent(example-3@200'and 2QI009
construction to the following:
10.Static water level below top of casing: � (ft) Division of Water Resources,Information Processing Unit,
kwater level is above casing,use ,+,, 1617 Mail Service Center,Raleigh,NC 2 7699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Centeer,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24e.For Water Sunplv&c Injection Wells: In addition to sending the form to
}{TH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type; Amount: 1p�2 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016