GW1-2021-06810_Well Construction - GW1_20210110

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ELL CONSTRUCTION RECORD For Intemgl Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
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Mitchell Dean Cook zg w+>rE gr7Es
FROM TO DESCRIPTION
Well Contractor Name 2,R. ft
2043 A ift. s�2 ,�-ft.
NC Well Contractor Certification Number 1..(1UTERA'$IIYGY.for tniiltrcltgpl(vYlils?UI2.la
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft.
Company Name 16:i ,SR GA$ .OA AVG. E6f eriii6l40'
FROM I TO DIAMETER I THICKNESS I MATERIAL u
2.Well Construction Permit#: % 0/EZ ft. ft.
List all applicable well permits(le.County,State,Variance,injection,ere.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) QR �iential Water Supply(single) ft. ft in.
8. ROUT❑htdustrial/Commercial ❑Residentiel Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation ft. 7 ft.
Non-Water Supply Well:
❑Monitoring ❑Recovery ,ft ,• fa
s >
Injection Well: ft tr.
❑Aquifer Recharge ❑Groundwater Remediation 19 S";D/O Y.. l 1'tAC�1C f ra t,cnb:e :
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERAI, I EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
�. QDIt11)L-1N�rGU'Csr'attaa adifit►6"galYeheef's;ifin'"esba •f,;Yz,�'t.,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIMON color,hu4nM soil/rock tram size etc.)
❑Geothermal (Heating/Cooling Return ❑Other ex lain under#21 Remarks) ft• rt
ft ft.
4.Date Well(s)Completed:CS,5o7J�/Well ID# /w/A ft. ft
P J"*
5a,Well Location: ] ft ft
jl./: ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft ft
nm
/-A ek r>—Jr/re Ago r:a FG rt fl prOfiE8S1I1g UfiZlr
Physical Address,City,and Zip 21.,RENfi1RK;,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,oneylat/long its sufficient) �
i.] f J �i ✓ /L N {7. 9ct���J.J I a� r� W �. G�°
Signature of Codified Well Contractor _ Date
6.Is(are)the well(s): (aPerfnanent or ❑Temporary
By signing this form,!hereby cer16 that the well(s)was(were)constructed in accordance
with 13A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91No,.-- copy ojthis record has been provided to the well owner.
Ijthis is a repair,fill out known well construction information and explain the nature ojthe
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 41 ,5 (ft.) 24a. For Ajl Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferenr(example-3@200'and 2 a/00') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: 16 addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 Cen fer;Raleigh,NC 27699-1636
13a.Yield m Air lift 24c.For Water Supply&Injection Wells:
(gp ) GI Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013