GW1-2021-02012_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 TO DESCR ION
4448A ft. ft. -2 Z 7
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&I/
ft. 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• W Z0• eZ eZs FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc.) f[. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) lWesidential Water Supply(single) ft. ft. in.
IndustriaKommercial []Residential Water Supply(shared) 18.GROUT
Irn ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C7
Monitoring ®Recovery ft. r
Injection Well:
ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft• tt.
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
Geothermal(Heatin Coolin Return) _Other(explain under#21 Remarks) R ft. 22 ft.
4.Date Well(s)Completed: 'a Well ID# 2Z fr. y0 ft. •o�tPG /C��/
5a.Well Location: y0 ft
h\04 I Ft s.7
Facility/Owner Name `,`A Facility ID#(if applicable) ft. ft.
30
9 O A l� S W+�+A rW-Q_13Ay%-k_ ft. ft.
Physical Address,City,and Zip
ft. ft.
Oc,e- c.c- `t t3tP 4 a %to l'7 21.REMARKS I v
,l,..ition Processing Unit
County tjParcel Identification No.(PIN) slactirm
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certificatio
°0"7r a2 N "7q° It.M W
6.Is(are)the wellll(s)�Permanent or []Temporary of Certified Well Contractor Date
By signing this form.I herebv 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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: c/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 39- (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
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 WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�
13a.Yield(gpm) / L_ Method of test: 24c.For Water Supply&Iniection Wells: In addition to sending the form to
/J�7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: t /d 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