GW1-2021-07641_Well Construction - GW1_20211201

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Intemqi Use ONLY:
L Well Contractor Information:
Mitchell Dean Cook . ................. . ...........
FROM To DESCRIPTION
Well Well Contractor Name fA
2043 A J635ft 19�X'
rr ft.
NC Well Contractor Certification Nurnbor
FROM TO DIAMETER
THICKNESS MATERIAL
MATERIAL
Dennis Holland Well Drilling, Inc. ft. .5,OR
Company Name 44ft :t4i'Q
FROM TO LEAW THICKNESS MATERIAL
2.Well Construction Permit N: 0 9 �' a z 'e7 & ft. I
List all applicable well permits(i.e.COu"OK State,Variance,Injection,e-
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: WE
FROM I TO I DIAMETER-_F�SLOT SIZE THICKNESS I MATERIAL
ClAgricultural ONfunicipal/Public tt.
", [ in.JI
OGeothermal(Heating/Cooling Supply) L06sidential Water Supply(single) ft. In.
01ndustriai/Commercial ClResidential Water Supply(shared)
01niation FROM ft. TO ft I MATERIAL EMPLACEME r
Non-Water SupplyWell: to
OMonitoring ORecovery 3 .20" ft'
Infection Well: fL ft.
OAq,,f,,Recharge OGroundwater Remediation ..... .. ......
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL
EMPLACEMENT METHOD
OAquifer'rest OStormwater Drainage ft.
OExperimental Technolo ft. ft,
gy OSubsidence Control
OGeothermal(Closed Loop) OTracer
FROM TO DESC ONE tcolor,-nArdfleS,%1301Vrock type,grain size,etc.)
I OGeothermal(Heating/Cooling Return) 00ther(explain wider#21 Remarks) ft. ft.
ft. ft.
4,Date Well(s)Completed: Well ID# A/.1A, U
Sa.Well Location: C�_
ft.
Facility/Owner Name 6 9 /.)_J ft.
Facility ID#(ifapplicable)
fL ft.
R jr) IL ft.
Physical Address,City,and ZipMee "
7
C-_007 '•
2q
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one latilong is sufficient)
3151, 1 :2 9-24 N g W A!P
6.Is(are)the well(s): WWe-rmanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert6fy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well; OYes or V?q10_ copy ofthis 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 tinder#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.Number of wells constructed: 1 You may use the back of this page to provide additional well site details or well
For multiple injection or non-water suppl construction details. You may also attach additional pages if necessary.
y wells ONLY with the same consiruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: 90� J ft.) 24a. for A Veils: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdt fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use , 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6"
(lu.) 24b.For In'egfion Wells ONLY: In addition to sending the form to the address in
12,Well construction method; Rotary 24a above, also submit a copy of this form-within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen'ter,Raleigh,NC 27699-1636
13a.Yield(gpm).. f S Method of test: Air lift 24c.For Water Supply&Injection Wells:
13b.Disinfection type: H & H Also submit one copy of this form within 30 days of completion of
12 Amount: oz. well construction to the county health department of the county where
constructed.
Form OW-1 North Caroline Department of Environment and Natural Resources—*Division of Water Res aurces Revised August 2013