GW1-2021-02058_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 DESCRI
k. k.
4448A
e. k.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ilcable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft. 1 41 k• 6 5/8 in. 1 .188 SiislL
Company Name
81 � ' 16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. fL in.
3.Well Use(check well use): rt. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public fr. fr. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
In
Residential Water Supply(shared)
18.GROUT
II'TI ation FROM TO UJTERIAL EMPLACE ENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. o ft. 64.
Monitoring 1311ccovety ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test r3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain An,dc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) O k. ` ft ZY
4.Date Well(s)Completed: Z' Well ID# 2 ft. BOO k. ��,
5a.Well Location: k. ft. IV ED
��Irvin
Facility/Owner Name Facility ID#(if applicable) k. ft.
1#6� C4A4te Cl" 2a( 2 -EsLfim AM
Physical Address,City,and Zip ft. ft. Information Processing Unit
n k 11. ,., 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / 1 22.Certification•
35V 1 l-J-4q N q° -CO •0) W �' o -fit
6.Is(are)the well(s)(0Permanent or 137remporary Signature of Certified Well Contractor Care
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: [3Yes or Jallo 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-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: t7a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerew(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 19 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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 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: /IFO 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