GW1-2021-00476_Well Construction - GW1_20211222

a'Print�Form
�VELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.WATER ZONES
Well Contractor Name FROM T'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. I ft. 8 5/8 in. .188 G.STEEL
Company Name
- �y 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: SO 54 µ+\f-LrN 7- , 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 SLOTSIZE THICKNESS MATERIAL
Agricultual OMunicipaUPublic ft. ft. in.
_11 Geothermal(Heating/COoling Supply) OResidential Water Supply(single) ft. ft. in.
__i Industrial/Commercial Residential Water Supply(shared) 18.GROUT
_ In'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. PORT.CEMENT POUR
:)Monitoring DRecovery
Injection Well:
ft. ft.
I Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stonnwater Drainage
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
_i Geothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc.l ft. ' It.
11
4.Date Well(s)Completed:l�•11 L I Well ID# '(.0 ft' y e ft'
5a.Well Locatio
` �
f I,;--I,-
Facility/Owner Name Facility ID#(if applicable)
Physical Address,City,and Zip ft. ft. DEC 2 2 2021
1�� e_ 8 7 S- Lo 8 I 21.REMARKS
County Parcel Identification No.(PIN) Do,SECT VA
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufficient) 22.Certifica
3S° SI• ZZI I I
N Igo Z$. 602 W -II'LI
6.Is(are)the well(s)oi Permanent or Temporary Signature ofC we ontractor Date
going this farm, 1 herebv certify that the well(i) was(were,)constructed in accordance
7.Is this a repair to an existing well: EJYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
(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'lhis fmvn.
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: U SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( O (ft.) 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,
Ifwater 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
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) ®t Method of test: AIR ROTARY 24c.For Water Supply&Iniectidn Wells: In addition to sending the form to
L/ the address(es) above, also submii one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: /0Z 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