GW1-2021-02127_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 P PION
rt. ft. _ 2
4448A
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. ft. 6 5/8 in. .188 STEEL
Company Name
16.INNER CASING OR TUBING eothermal closeddoo
2.Well Construction Permit#: L4 7 5 W U—N Z G FROM TO 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, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SI7.E THICKNESS f•1A'rF:R1A1.
Agricultural OMrmicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial 1[3Residential Water Supply(shared) I&GROUT
Irrigation FROM TO ATERIAL EMPLACE VT METHOD&.AMOUNT
Non-Water Supply Well: ft. 2v tt. a tom.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rook e, rain size,etc.)
ft. ft. O
IQ zz
4.Date Well(s)Completed: �9 r Z' Well ID# ft. 20 ft. Q c k
Sac.Well Location:
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✓ko-y,� A i
Facility/Owner Name D� Facility ID#(if applicable) ft. ft
'Pot Ci Groxp. . A')a.5-3
Physical Address,City,and Zip c, ft. ft. v
p`o a5gg 3 21.REMARKS 4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laattflongisis sufficient) �/ 22.Certification
000 e 13 N l�lD II- W c -Z)
6.Is(are)the well(s) Permanent or Temporary S' lure ofCcrtifie AreTl Contractor Date
B this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 01C.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: /�`�0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi(ferent(example-3@200-aannd 2@100') 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 Infection 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&Infection 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: /20 Z 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
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