GW1-2021-07376_Well Construction - GW1_20210921

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID COOK 14.WATER ZONES
FROM TO DESCRH11•10
Well Contractor Name
/ n. / ft. ,f47
4495-A �O
IL
NC Well Contractor Certification Number 15.OUTER CASING for multi- ,s wells OR LINER f applicable)
DAVID COOKS PLUMBING FROM TO DIAMETER THICKNESS MATERIAL
ft. fL !in. SG 7 V (�t
Company Name
16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft. It. rn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP Y , FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:]Agricultural OMunicipal/Public /tt. ft. in. V yV rJ
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) v ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
irri ation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: C3 ft. ft.
Monitoring Recovery ft.
Injection Well: ft. ft.
Aquifer Recharge OI Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OJ Stormwater Drainage 4�r ft. tt.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,harda soiVrock tyiu in faze,etc
O ft. 5 ft. O
4.Date Well(s)Completed:08/24/2021 Well ID# ft. J ft. a �.
5a.Well Location: ft. $.
CURTISS LEE MATTHEWS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) R' wlil ft- C G
3605 COBB DAIL RD FARMVILLE, NC e. o ft. t�✓�
Physical Address,City,and Zip ft. ft. 1
PITT 82689 21.REMARKS
County Parcel Identification No.(PIIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification' /
N W ' U+ 7
6.Is(are)the well(s)OPermanent or Temporary Signature'of ertified Well 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: E]Yes or X)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
If 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#11 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
filled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: kD (f0 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diijerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: /Z (N Division of Water Resources,Information Processing Unit,
If water level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/� above,also submit one copy of this[.form within 30 days of completion of well
Vc/
12.Well construction method: r/� T �`1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Z�c Method of test: 24c.For Water SuDvly&Iniectioil Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ( Amount: tar 0 z 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 r ___ Revised 2-2272016__.__