GW1-2021-02132_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor information:
Christopher Watcher 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. (,;, PLINER
4448ANC Well Contractor Certification Number 15.OUTER CASING for multi-cased wellsif a licable
Cummings Developments, Inc FROM TU DIAMETER_ S MATERIAL
+1 ft. ft. 6 5/8 rn• STEEL
Company Name 16.INNER CASING OR TUBING eothermilelosed-loopl
2.Well Construction Permit#: t•4ut#4 WV- L N Z b 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 '1'O DIAMETER SLOT SIZE 'THICKNESS MK'TERIAI.
Agricultu al [3Municipal/Public tt. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft• ft• in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
71 Irrigation FROM TO N16YERIAL EMPLACEMEN ETHOD&AMOUNT
Non-Water Supply Well: ft. ZG ft.
Monitoring ORecovery
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM I TO I MATERIAL_ I EMPLACEMENT METHOD
Aquifer Test [3Stomrwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) QTracer 20.DRILLING LOG attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain sirr,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Ro ft, ft. 1
4.Date Well(s)Completed 7—Z I Well ID# 33
ft. tt.
5a.Well Location:
—\445 g
Facility/Owner Name Facility ID#(if applicable) ft. ft. ( 21
1
K 1d �w �� alas ft. -
4S41 5 1l� ��or --
Physical Address,City,and Zip p ft. ft.
Y7 cnt- `t`(a[a 0 it 6 7A 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 s fficient) 22.Certifrcati
3(°oo, N �l�l° u V10 W ,�
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By sig<n�his form,i hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if/his is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / / o A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different jerantple-3 n 200'and 2Q100') 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 7LLS 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: AJ 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