GW1-2021-06812_Well Construction - GW1_20210110

WELL CONSTRUCTION RECORD
For Intemql Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: €
Mitchell Dean Cook 14 wATER7OiYES s. :;:
FROM TO DESCRIPTION
Well Contractor Name �'ft. �� "ft
2043 A fL ft.
NC Well Contractor Certification Number 1S.JOUTER'CASINC forrmaltr=cesed wells,OR'I INER lti6 hca6le' '
FROM TO DIAMETER TRICKINESS I MATERIAL
Dennis Holland Well Drilling, Inc. { r rL lavA rt. .'.! in.
Company Name 16:iNNER'CA$ING ORiTUBING;``eotherinnlclo�ed lob ti-;
FROM 1.TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: r ! a „z ) �� ft. ft. is
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
fL fL jib.
3.Well Use(check well use): ;17.rSCRBEN ';
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public ft. fL in.
❑Geothermal(Heating/Cooling Supply) lg$�idential Water Supply(single) tr. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 181'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation r tL ft.
t
Non-Water Supply Well:
❑Monitoring ❑Recovery S' tr. . ZC> fL 1. .. ��` . '�`.. as:5✓ �
Injection Well: fa ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.�SAND/GRdVEl.PACIB ifs Leible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑StormwaterDrainage fL ft
❑Experimental'technology ❑Subsidence Control
'.2d:`11RILLING'%0G attectit`iiddrtionel'riheets ifuecessa `
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,baWnIS soiltrock •run sin etc.
❑Geothermal (Heating/Cooling Return ❑Other explain under#21 Remarks) tL ft.
f fL ft. 4
4.Date Well(s)Completed: 10-5-2y"'Z I Well ID# AleAl/
fL it
5a.Well Location: ft. tL
i
.,5, -'":..&'•b.lt'. /y'6� r*`l-.'3� /'lli r ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) fL ft. J
Lz fL tL ��� 4' 1-I�LAt; rJlnl fJ. V1ZI
Physical Address,City,and Zip 21::REMAI3KS' ^ "i+ i rill
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
t
FAN ` % W �
Sim a of Certified Well Contractor Date
6.Is(are)the well(s): OP manent or ❑Temporary By signing this form,I hereby cert6 that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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: J (ft.) 24a. F2r All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(example-3@200 and 2@100') construction to the following:
10.Static water level below top of easing: / %/% (ft.) Division of Water Resources,Information Processing Unit,
ljwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For Infection Wells ONLY: in 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) r/ Air lift 24c.For Water Supply&Injection Wells: 1
/s 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013