GW1-2021-07410_Well Construction - GW1_20210921

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R L`ii.`IIJNSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Christopher Watcher ci %T\
WATER:ZONES
Well Contractor Name +�— UVOM 1 TO 1 DESCRIPTION ~
4448A t��Q i.
ft. k.
NC.Well Contractor Certification Number
��,�'°� 3��yR •�OUTIsR: TU1NG7 fdr fii D AMETEReIIs
Cummings Developments, Inc FROM
OR 1CKNESS a�IrMATERIAL
Company Name
+t ft. fL s in. PVC
/� -1iigl'N ER C" ING ORTUBING'('eothei'milxiosed lao ',�.� '.
2.Well Construction Permit#: �' �j,���{�L..—01 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.L7C,County,State,Variance,etc.) ft. ft. 1 in.
3.Well Use(check well use): ft. k. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER I SLOTSIR THICKNESS-1 MATERIAL
Agricultural Oi Municipal/Public ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
Industrial/Commercial E31tesidential Water Supply(shared) ,GROUT.F'.
Itrioation FROM TO ATERIAL EMPLACEM NT METHOD&AMOUNT
Non-Water Supply Well: S ft. k
Monitoring _ Recover s
Y ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remcdiation ft. k
-19.'SAND/GRAYEI;•PACK if a"lrca6le nt
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal Closed Loop) Tracer r:. _
( P � 20:11RIb'litNG�LO:G'ahach;ed"diHanit?sheets�if.necessa
_;Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness soitlrock a rain size,erc.l
4.Date Well(s)Completed: " Z well ID# k• 39 0 ft.
5a.Well Location: ft. ft.
Tl ft. M
Faciliity/OwneerNamee Facility ID#(ifapplicable) k• It.
7! D{ /12 C-I do-4-A �IV it q•L7t�� �1 / ft. ft.
Ph.ical{{Address,City,and Zip . (�it ft, ft.
7Ui 1• �� i 8*7 21:,REMARKS g
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) { 22.CertiSeati
t! / 1
-5-2�
6.Is(are)the well(s)lft Permanent or Temporary gnaturc tcd Well Contractor Date
signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or R)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
!f this is a repair:fill out known well construction information and explain the nature of the copy ofthis 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:9.Total well depth below land surface: SUBMITTAL.INSTRUCTIONS
For �� (ft•) 24a. Far All Wells: Submit this form within 30 days of completion of well
multiple wells list a!!depths ifdifferent('example-3@200'0'and 2QI00} construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources In
I(water(evel is above casing,use"+" � , formation Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
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,rota construction to the following:
g rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield{gpm} �� Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit ohe copy of this form within 30 days of
13b.Disinfection type: IiTtt Amount: completion of well construction to the county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22-2016