GW1-2021-00474_Well Construction - GW1_20211222

�� P,int�Form;
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
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. I T15
ft. 6 5/8 in. .188 G.STEEL
Company Name
I, _ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 47T a W ELIu Z O 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 nMunicipal/Public ft. ft. in:
1 Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft ft in.
IndustriaUCommercial 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 130roundwater Remediation ft.
19.SAND/DlGRAVELPACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_ Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock e;:-'i.-we,etc•1
_ Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks)
4.Date Well(s)Completed: " l Well ID# q ft. 33 ft. Rom)
55a...Well Location:
� M
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3a 3 5ou�+-r N� �� ykx Mon ZA ft. ft. DEC
t
Physical Address,City,and Zip ft. ft.
0.9911 Laos J-1 21.REMARKSP no
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N 0a y W
6.Is(are)the well(s)o Permanent or 13Temporary Signi f Certific Contractor Date
By ignin form,I hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or EJNo it NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/fthis is a repair.fill oul known well construction information and explain the nature ofthe 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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i (� SUBMITTAL INSTRUCTIONS
9.Total.well depth below land surface: �l 3(o A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@ 100') 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
11.Borehole diameter: 6 (in.) 24b.For Injection 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) CO Method of test: AIR ROTARY 24c.For Water Supply&Injection 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 J 0 Z 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