GW1-2022-02971_Well Construction - GW1_20220228

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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 DESCRIPTION
4448A
rr. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Hcable
CUMMINGS DEVELOPMENTS , INC FROM TO DIAMETER THICKNESS MATERIAL
+1 H. 1" 6 in. PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: W Z 1 - OO 5 LP 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 'I'O DIAMETER SLOT SIZE 'THICKNESS MATERIAL
Agricultural 13Municipal/Public fr. ft. in.
Geothermal(Heating/Cooling Supply) taResidential Water Supply(single) tt. fr. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft. PORT.CEMENT POUR
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 OStormwater Drainage
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) ©Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
fr. 12, ft. -O)
4.Date Well(s)Completediz- -0 Well ID# 21ft.
o H.
5fMa�.nWell Location: (/
1 C"A D l_O",f S ft. ft. 1
s
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and Zip q t, q p F►
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 syfficient) 22.Certificatio
3�d 01• �g� 1 N 'Igo X-lig W
6.Is(are)the well(s)oPermanent or Temporary gnature o red ell Contractor Date
By signing this form,i hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this it 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 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 l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: p� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �0✓Q y (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7 ol (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) a Method of test: AIR ROTARY 24c.For Water Supply&lniection Wells: In addition to sending the form to
!///q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 7Jl 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