GW1-2021-01045_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW 1) 'T Prrnt,Form
For Internal Use Only: -
1.Well Contractor Information:
CHRISTOPHER WATCHER
14:WATER ZONES
Well Contractor Name FROM TO UESCR 'tON
4448A ft. " / ;1 C/
NC Well Contractor Certification Number f t' ft. V /
IS.OUTER CASING(for multi-cased:wells OR.LINER"if a licable) -
CUMMINGS DEVELOPMENTS , INC FROM TU DIAMETER THICKNESS MATERIAL
Company Name +1 ft. / ft' 65/8 in, .188 G.STER
lb. C
2.Well Construction Permit#: . eo
9 r-I 1 WL _Al Z I FRO INNER M TO DIASING.OR TUBING thermal closed-loo
AMETER THICKNESS MATERIAL
List all applicable well eairh uetioa peruuts(r.c•.UIC,Comity,State,I'nr ivaee.I".) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Municipal/Public ft.
i Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. in.
hldustrial/Commercial Residential Water Supply(shared) ft.
Irrigation 18.GROUT
FROM TO MATERIAL EM
Recovery
EMPLACENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft.
PORT.CEMENT POUR
Monitoring
Injection Well:
Aquifer Recharge Groundwater Rcmediation
19•SAND/GRAVEL PACK(
Aquifer Storage and Recovery Salinity Barrier if a H able)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stomtwater Drainage Ct. ft.
Experimental Technology Subsidence Control «• tt.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG attach additional=sheets if,necessar
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks] FROM To DF,SCRIPTION(color,hardness,soil/rock type, rain size,etc.)
ft. �ft. •/
4.Date Well(s)Completed: ' — Z1 well ID# �r. isq� ft, vG
52.Well Location: ft. ft C
S� C,a,•�r R. rt.
Facility/ crNamc Facility ID#(if applicable) ft• ft.
ft.
Physical Address,City,and Zip ft. ft.
00 9zl9a3 , r
L t= 21,,RElVIARKS 1 County G'tParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
1 p f 22.Certificati
Is V N Zq Iq� 9g5 W
6.Is(are)the well(s)oPermanent or Temporary gnat Certified Well Contractor �Z• _�t
Date
7.Is this a repair to an exiStin By signing this forni,/herebv certify that the ivell(,$)was(were)constructed in accordanceg well: E)Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out known ivell construction information and explain the nulure of the copy of this record has been provided to the well owner.
repair under#11 remarks section a•at the back of this farm.
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)
For multiple wells list all depths;fd different(exa,nple_3@100'and 2@1001 24s.
For All Wells: Submit this form within 30 days of completion of well
3 construction to the following:
Static water level below top of casing:
/f water level is shave casing,use (ft.) Division of Water Resources,Information Processing Unit,"+"
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 Supply&Iniection Wells: In addition to sending the form to
13b.Disinfection Type: HTH the address(es) above, also submit'one copy of this form within 30 days of
Amount: erzU 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