GW1-2021-02133_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: 7
Christopher Watcher 14.WATER ZONES
Well Contractor Name FROM 1'O DESCRIPTION
ft. ft.4448A Li
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
Cummings Developments, Inc FROM TO DIAMETER THICKNESS MATERIAL
*1 ft' ft- 6518 In' 1 .188 STEEL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#: 4 8 W GLN Z I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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 MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irri•ation FROM TO TERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fr. G ft. V t:..�
Monitoring 13Recovery
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 r3 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soiVrock e, rain sins,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) D ft. _T! It, J o/
4.Date Well(s)Completed: Well ID#
5a.Well Location:
fr. ft.
ehhs MSSL I
Facility/Owner Name Facility ID#(ifapplicable)
ci ft' ft• m Yvy«
171 Do-k5 TJ 27315a
Physical Address,City,and Zip
gp�R7Op p� 21.REMARKS
r
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.Certification:
3G*a 3 . . 'Lit a W �� S Q L
6.Is(are)the well(s)aPermanent or 131remporary Si ed Contractor Djtc
By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or Jallo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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: "/20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@@100') construction to the following:
/
10.Static water level below top of casing: / .J W.) Division of Water Resources,information Processing Unit,
!(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: 3002 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