GW1-2021-00456_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM .1'0 DESCRIPTION
4448A ft. ft. I Z 3
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-loop)
2.Well Construction Permit#: � S W F L 12 21 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): et. ft. in.
Water Supply Well: 17.SCREEN
FROM '1'O DIAMETER SLOTSIZE 'THICKNESS MATERIAL
Agricultural Cj Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) W-Sidential Water Supply(single) @ fr in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
Monitoring QRecovery
Injection Well:
ft. ft.
j Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK if a licable
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
Experimental Technology [Subsidence Control
Geothermal(Closed Loop) OTfacer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck type,gmin sin,etc.)
Q Q IL ; ft.
4.Date Well(s)Completed: I ✓-Z Well ID# ?9 ft. Z
5a.Well Locati
71AL.-
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5151 urlinA6n abil ft. ft. EC 2 2 2021
Physical Address,City,and Zip IJ
ft. ft.
4"000- 9
1 I OO'410(o O 21.REMARKS ���pp .~y^�
County Parcel Identification No.(PIN) 17TO1`)P(MU PNCESSIM3 INF
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific
L° l� • � 351 N W II-3-2�
6.Is(are)the well(s)0 Permanent or 13Temporary Si of Certified Well Contractor Date
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: DYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill 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:
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: I zoo
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Vi/ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdi/jerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 19 (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
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) Method of test: AIR ROTARY 24c.For Water Supply&Iniection Wells: In addition to sending the form to
HTH the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �?ao -t 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