GW1-2021-00462_Well Construction - GW1_20211222

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ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM 'I'O DESCRIPTION
4448A
ft. ft.
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. 4 3 ft. 6 518 : m, .188 G.STEEL
Company Name 1
(�/7� q�9W,1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: "1" rl V E LN a I 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. it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSI%E THICKNESS MATERIAL
i Agricultural nMunicipal/Public tt. ft. in.
i Geothermal(Heating/Cooling Supply) []Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
_j Irri atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. PORT.CEMENT POUR
:),Monitoring 13 Recovery
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)StormwaterDrainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _.)Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain sim,etc.)
O ft. 22 ft. oil
l
4.Date Well(s)Completed: ' ''Zk Well ID# 22 ft. 32 ft.
Sa.Well Location: 3120 rt. z-) L
l^M t i4 `1 ft. ft.
Facility/Owner Nauad Facility ID#(if applicable) ft. ft.
—
Physical Address,City,and eip rt rt WMIOMN 1"1 VM3SING '\ —p Ts
5 u al.0 Z 10110 9 21.REMARKS
County` C' Parcel Identification No.(PfN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laatt/long is sufficient) Q —f 22.Certifieati
3if/06 �� �O�gr N 23 W' 1 I
6.Is(are)the well(s)0 Permanent or OTemporary aturc cnified Well Contractor VV Date
y signing this form, I herehv certify that the well(s)was(weir)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
Ifthis is a repair,fill our known well construction information and explain the nature ofthe copy ofthis 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: 3 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent lexannple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1$ (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 Injection Wells: In addition to sending the form to the address in 24a
1 ROTARY above, also submit one copy of this form within 30 days of completion of well
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
/J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: J 2 0'Z completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources] Revised 2-22-2016