GW1-2021-00455_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4448A ft. ft. 50) V
ft. fL 9 t To M 2. 4 ' I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased'wells)'OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. �✓� ft. 6 5/8 in.
.188 G.STEEL
Company Name 16.INNER CASING
OR TUBING(geothermal closed-loo
2.Well Construction Permit#: LA Ot D LA WE LN Z- 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. fL in.
:)Geothermal Geothermal(Heating/Cooling Supply) M,Residential Water Supply(single) ft. tt. in.
Industrial/Commercial nResidential Water Supply(shared) 18.GROUT
�Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p ft. 20 ft. PORT.CEMENT POUR
Monitoring DRecovety ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge �Groundwatcr Remcdiation
19.SANDIGRAVEL PACK if applicable)
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stornlwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#2l Remarks) FROM TO DESCRIPTI N(color,hardness,soil/rock e, rain size,etc.)
ft. ft.
4.Date Well(s)Completed: '2 Well ID# 3 ft. .200 ft.
5a.Well Location: ft.
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Facility/Owner Name Facility ID#(if applicable) ft. ft. tit
( e�-1 C�S3 ft. ft. tr'v; P.
gyo0 �Q1f\4t�.k2 /^.�� �fCI�IN� ft. if!r
Physical Address,City,and Zip ft. T -
SSM
OAmw,4 �(z_ !3 o 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p 1 22.Certifica
3S0 SZ•iy�1 N 'l ID K- 0KJ I W
6.Is(are)the well(s)oPermanent or ElTemporary gnat red well Contractor
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or ®No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/(this is a repair,fill out known well construction information and explain the nature ofthe copy q/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 of well
construction,only 1 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: zQO (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3 a 200'1nd 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,u .,se"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.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) / �p Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: `��L 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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