GW1-2021-07428_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
?Well Contractor Information:
Christopher Watcher la.WATERZONES
Well Contractor Name IDFROM TO DESCRIPTION
4448A L{ lit/
NC Well Contractor Certification Number H1 IS.OUTER CASING for multi-cased wells O r
(.
R LINER ifa"I livable
Cummings Developments, Inc Q V yr�, FROM TO DIAMETER THICKNESS MATERIAL
+1 It. ft. 1 6 -, in. I PVC
Company Name
p,,,}�� INNER CASING ORTUBING eothermal.ciosed-loop)
2.Well Construction Permit#: W 7-1 �� �L7�T Q Se t o FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,BMXf ,Stu riance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. ini
Geothermal(Heating/Cooling Supply) JgResidential Water Supply(single) ft. ft. in.'
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ hTi ation FROM TO ATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. /Lp ft. U
Monitoring 13Rccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a liciible
J Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG`,(attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sic,etc.)
10 ft. S"3 ft.
4.Date Well(s)Completed: �2 Z Well ID# 'f ft. Ro ft. G
5a.Well Location:
a
Facility/Owner Name Facility ID#(if applicable) ft. ft.
8�$0'3 ft. it.
4So N pay,�, CAN.-d 'I 1doong(
Physical Address,City,and Zip n y ft. ft.
1 XGl/�QL� I ()Of Ot q 1 `i S� 21 REMARKS `
County Q, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) t 22.Certifica
A600 •q32 I N 2S0 W
6.Is(are)the well(s)oPermanent or Temporary Si�,,gning
tified Well Contractor Date
form,I herebv certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C-0200 Well Construction Standards and that a
Ifthic is a repair,fill out known well construction information and explain the nature ofthe copy gf1his 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 iftliferent(example-3@200'and 2@100') construction to the following:
00
10.Static water level below top of casing: J 9 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) Z-6 Method of test: 24c.For Water Supply&Infection 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: O Z 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
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