GW1-2021-00457_Well Construction - GW1_20211222

' WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
e
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
`ht
4448A rr. it. a�•Y
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
Company Name .1 ft. Li i
rt. 6 5/8 in' .188 G.STEEL
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: LkeB EW I--1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State, Variance.etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM '1'O DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public tt. ft. in.
I Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial rl Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
Monitoring ®Recovery
Injection Well:
Aquifer Recharge [3Groundwatcr Remediation
Aquifer Storage and Recovery Salini Barrier FROM
SAND/GRAVEL PACK Ma applicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EJStonnwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
_i Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _j Other(explain under#21 Remarks) FROM I To DESCRIPTION(color,hardness,soiVrock h e,grain sirx,etc.)
ft. ft.
4.Date Well(s)Completed: _ Well 1D# R. Zyd rt.
Sa.Well Location:
ft. ft.
12r,o1.6"
Facility/Owner Name Facility ID#(if applicable) ft. rt.
°s
�399 &,Ler.5ri ar I r rc. n• �:" �• A �,�i }
Physical Address,City,and Zip
vIU q� ram_ Sn 5&3 A q 4-4 2) 21.REMARKS
County Parcel Identification No.(PIN) 1
KA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: )r
(if well field,one lat/longis sufficient) —7(�j� ! 22.Certif ti0
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6.Is(are)the well(s)oPermanent or Temporary ignamrc of Cc ell Contractor Date
8 ng this form,l hereby certify thbt the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consrniction 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 oj'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-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: A) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii ferent t'sample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 42� (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 Infection 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
( ,r.e.auger,rotary,ry,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY;�LLS 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
the address(es) above, also su 't'one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: ?'�Z completion of well construction o the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016