GW1-2021-00555_Well Construction - GW1_20211222

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r._pohi.Form
WELL CONSTRUCTION RECORD (GW-1I For Internal Use Only:
1.Well Contractor Information:
CHRISTOPHER WATCHER 14.,WATERZONE$-
Well Contractor Name FROM I'D DESCRIPTION
4448A ft, ft. $ Z
ft. ft.
NC Well Contractor Certification Number
15.CUMMINGS DEVELOPMENTS , INC FROMUTER CASING.(for m D AMETEReIIs"OR ICKNESS.BNER-M II MATERIAL
Company Name +� ft. ft. 6 in. PVC
-`n 16ANNER.CASING.OR TUBING eothermal closed4ba
'Wry _
ni
2.Well Construction Permit#: 1 ®31 e1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(te.UiC,County.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ,17-SCREEN
Agricultural FROM To DIAMETER SLOTSIZE THICKNESS alA'fERIAI.
MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) pResidential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) ft. ft. in.
I8.GROUT
Irrigation 7ft..
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: PO ft. PORT.CEMENT POUR
Monitoring RecoveryInjection Well:A uifer Rechar a ft.
q 6 �Groundwatcr Rcmcdiation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK'(if a licable);_
Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stonnwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRiLL[ G'LOG(attach additional{sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) Fao TO DESCRIPTION[color,hardness,soiltroek type.gnin srrx,etc.)
ft51.
4.Date Well(s)Completed: L0. ft.?&_1; Well ID# t ft. D ft. rJc p
5a.Well Location:
A
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vl _Irtnn
Facility/Ow r Name Facility ID#(if applicable) ft• fL ` 1
3318 tTx 1Z t,� �►�`�►�� VA e is S a 7� n. T�?�e P;y�
Physical Address,City,and Zip © o (� fI. ft.
1 Jt© O t 21.REMARKS _
ounty Parcel identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) ��p./� 22.Certificatio
3f.°l� I/,i� _ N 7Q 0t191a-7
6.Is(are)the well(s)oPermanent or Temporary urc of I led Well Contractor Date
By signing this for•nn, l her•eGv certify that the ivell(c)was(were)constructed in accordance
7.is this a repair to an existing well: []Yes or EJNo with 15.4 NCAC 02C.0100 or 15A NCAC 02C"0200 Well Construction Standards and that a
If this it 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 wider#21 remarks section or on the back o/Ylnis fornn.
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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3 a 200'and 2 c 100')
9 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 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 forms 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 Supply&Injection 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: ZD 2 completion of well construction to the4 county health department of the county
where constnucted.
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Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016