GW1-2021-07408_Well Construction - GW1_20210921

W�L..L�PONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �y, r
Christopher Watcher i 14.WATERZONEs
Well Contractor Name ROM TO DESCRIPTIO
4448A ry,� t: ���J
'
o�Q
NC Wc11 Contractor Certification Number OUTER CASING:(for inulH»cased we :OR=LINER:if:a' liable::
Cummings Developments Inc `� ��� FROM TO DIAMETER THICKNESS MATERIAL
Company Name +t ft. 9 ft
6 in. .t
V
/� 16,INNER-CASING:ORTUBING keothermal:"'elo'S`eBlo�o
2.Well Construction Permit#: a Q 1 - y " LXY FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): fr. ft.
Water Supply Well: 17;SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Muaicipal/Public in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft.
:)Industrial/Commercial DResidential Water Supply(shared) I&GROUs
ITri ation FROM I TO MATERIAL EMPLAGEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. -0 IL
+t
Monitoring 1311ecovery (L ft.
Injection Well:
ft. ft.
Aquifer Recharge E3Groundwater Rernediation
19+,SAND(GRAVF,UF;ACK if h cable),
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage fL fr
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.,DRILLING:LO anach i dditton'al.'-fiotsdf iietiisa" ' ._ _
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/rock e, ra;n size,etc.)
0 fL ?3 ft. .5 1
4.Date Well(s)Completed: Well ID# 7.3 fr e fr
5a.Well Location: ft. ft.
Facility/Owner Name Facility lD#(ifapplicabte) ft. ft.
Physical Address,City,and Zip ft. ft.
6u 1\ 3©�s9rQ 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) f 22.Certification•
(o r,6 Si 13S N 7fo �"��! W
..� - -zJ
6.Is(are)the weil(s)EP Permanent or Temporary Si ore of 1 Contractor Date
fining this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or EJNo with 15A NCAC 02C.0100 or JSA NCAC 02C.0200 Well Construction Standards and that a
If this&a repair,fell 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:
S.For GeoprobelDPT or Closed-Loop Geothermal Welts 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: ✓f t,,�'/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ : /V (ft-) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells tilt all depths if different('example-3 ct 200'and 2@1001)
construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water 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
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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t9 Method of test: / '4 0 24c.For Water Supply&Iniection Wells: In addition to sending the form to
7� the address(es) above, also submit P one copy of this form within 30 days of
136,Disinfection type: NTH Amount: �O L completion of well construction to the county health department of the county
where constructed.
Fort GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016