GW1-2021-00464_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
CHRI STO PH ER WATCHER 14.WATER ZONES
Well Contractor Name FROM To I DESCRIPTION
4448A net ft.
NC Well Contractor Certification Number ft. fr.
15.OUTER CASING(for multi-cased wells)OR LINER if a licable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. � ft. 1 65/8 in tgS G.STEEI
16.INNER CASING OR TUBING„ eothermal closed4110
2.Well Construction Permit#: SDtp 4 (� N ELN FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction pernats(i.e.U1C,County,State,Madanee•elc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM 'I'O DIAMETER SLOTSIZE 'THICKNESS 1'IATERIAL
[]Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft.
Industrial/Commercial 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 DRecovery ft. ft.
Injection Well:
�
c Grif R
:)Aquifer Recharge ft. ft.
� g oundwatcr cmediation
Aquifer storage and Recover 19.SAND/GRAVEL PACK if a licable
y [)Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stonnwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTtacer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) FROM To I DESCRIPTION(color,hardness,soillmck type,grain sbr,etc.)
4.Date Well(s)Completed:1� I9• z1 Well ID# 2fl ft• •Z6 o ft. 0OGi�
/5�a.``_W--ell Location:
l 7 Ie s ft. ft.
Facility/Owner Namc Facility ID#(ifapplicable) ft.
1;?oa5 FaVPi�.k�r Ih ft. ft.
Physical Address,City,and rp ft. ft.
A\t m-,V�t, %.Sn7 Ato hIMas 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long issufficient) , 22.Certificati
?j�o ZI• I1�, N W n
II
6.Is(are)the well(s)oPermanent or Temporary �B,
turc of C• led Well Contractor Date
ung this f rim./hereby certify that the well(.$)was(were)constructed in accordance
7.is this a repair to an existing well: [)Yes or EINo ,15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Construction Standards and that a
tt:hie is a repair•fill out known well construction information and explain the nature ojl,e c'oPy 4j1his record has been provided to the rrnll owner.
repair under#21 remarks section or on the back ojthis_jorm.
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:
t�0 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 ifdflferent(example-3@200'a,d 2@1001
construction to the following:
10.Static water level below top of casing: 3
ifwater level is shove casing,use"+ I (ft.) Division of Water Resources,Information Processing Unit,
Ij "
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
12.Well construction method: ROTARY above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR ROTARY 24c.For Water Suoaly&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: 2-0O'Z 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