GW1-2021-00461_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 TO DESCRIPTION
4448A rt. ft. LJ 7
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased 4vells OR LiNER if a ticable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. I fL 6 5/8 in. .188 G.STEEL
Company Name
11,p,�y t �� 16.INNER CASING OR TUBING eotherroal closed-loop)
2.Well Construction Permit#: 1l p'1 J wG L N Z 1 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 SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/cooling Supply) ,Residential Water Supply(single) ft. ft. in.
i
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
7-1 Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff• 20 ft• PORT.CEMENT POUR
Monitoring InRecovery
Injection Well:
Aquifer Recharge nGroundwater Rcmcdiation 19.SAND/GRAVEL PACK if applicable)
i Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
I Aquifer Test [3Stomtwater Drainage
I Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
-J Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain sW,etc.)
() tt. ?2 U r
J t
4.Date Well(s)Completed: Well M# 7 3 ft. 5 t) ft.
Sa.Well Location:
-
1-1�
Facility/Owner Name 1 Facility ID#(if applicable) ft. ft. UEEC 2 2 2021
(04
ft. ft. ` `�( r�
Physical Address,City,
`and Zip
�SX]YtV� g g ill 1 q FS SS�1Q 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is guffrcient) 1 22.Certification:
3G°ol. 4s� N -no A. Y W
6.Is(are)the well(s)0Permanent or OTemporary Signature Certified W Contractor Date
By si ting this m,/herehv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E)No wi 15A AC 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 . this record has been provided to the well owner.
repair under#11 remarks section at,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 Ito provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r,^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 C50 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeliferent(example-3@200'annd 2@/00') 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,use.,+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 35'02 completion of well construction to 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