GW1-2021-00480_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
0
CHRISTOPHER WATCHER WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2
4448A O l
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a ticable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. U ' fL 6 in. PVC
Company Name 7
76.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: I e73.3 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 []MunicipaUPublic rt. ft. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
_11Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• PORT.CEMENT POUR
_;Monitoring Recovery
Injection Well:
Aquifer Recharge nGroundwater Remediation ft. ft.
19.SAND/GRAVEL PACK if applicable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stortnwater Drainage
Experimental Technology r1l Subsidence Control
:]Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
IGeothermal(Heating/Cooling Return) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain si x,etc.)
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t)t
4.Date Well(s)Completed: -!4'L' Well ID# 00
5a.Well Location: ft. ft.
Facility/Ow ?rName Facility lD#(if applicable) ft. ft. I;r 1 ti r .h
T'-)C-- 5 Suvl�,�c1 - n. rt.
Physical Address,City,and Zip
�4SWa ll noCa rs ���`9 21.REMARKS
County Parcel Identification No.(PIN) p �Ft"'.
t,,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certiticatio
%40 tb. N 79° It e 073
6.Is(are)the well(s)oPermanent or OTemporary rgnatur -r ificd Well Contractor Date
By signing this form, I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [DYes or EJNo with 15A NCAC 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 ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ,'^^!!��V SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: DG (ft.) Division of Water Resources,Information Processing Unit,
{fwater 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) 2— 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: 1002 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