GW1-2021-01977_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM '101 DESCRIPTION
4448A I- /27
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wellsl OR LINER if a licable
Cummings Developments, Inc FROM TO D1AMF.TE:R THICKNESS MATERIAL
+1 ft. ft. 6 in. PVC
Company Name _
}L�LI U 16.INNER CASING OR TUBING(geothermal closed-log
2.Well Construction Permit#: 1 FROM TO I 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. io.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
IndustrialfCommercial Residential Water Supply(shared) 18.GROUT
Irri gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. / „`
Monitoring 13 Recovery ,
ft. ftAlt
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Rcmediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSaIinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Storrnwater Drainage
Experimental Technology QSubsidence Control
Geothermal(Closed Loop) OTr'acer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DF:SCRIP'I'ION(color,hardness,so(orock e, rain size,etc.)
rt. �,� ft. (7
4.Date Well(s)Completed: Z It Well ID# ft. 7 ft. D� t
5a.Well Location: ". zoo ft. 4?n /�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Ph sical Address,City,and Zip W ft. ft.
21.REMARKS
County Parcel Identification No.(PIN) unil
C0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —:mLT}13"Qil
(if well field,one lat/long is sufficient)
/ /� q / 22.Certificatiol
360 2Z-�'l�t N �/ 097•0�s� f W
6.Is(arc)the well(s)ff)Permanent or Temporary c of Cerfi5ed Well Contractor Date
By signing this form, 1 hereby certify that the wells) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or @No 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 of the copy gfthis record has been provided to the well owner.
repair under#11 remarks section or on the back gfthis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: w V� (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii event(example-3@200'and 2Q100') construction to the following:
00
10.Static water level below top of casing: 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 Iniection 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
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) Method of test: 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: Gdp 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 Watcr Resources Revised 2-22-2016