GW1-2021-07642_Well Construction - GW1_20211201

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WELL CONSTRUCTION RECORD For Intemgl Use ONLY:
This form can be used for single or multiple wells `
1.Well Contractor Information:
Mitchell Dean Cook
FROM TO DESCRIPTION
Well Contractor Name � ft.
204.3 A ft. ft
NC Well Contactor Certification Number ?15%QQ ;LIt++ ' foi4iifiul' Ue•O )({`
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. • rt. ft. ,, In• -at Pv
Company Name
" ul'er'e eel° sd�1 p` t yF«•p s :�..
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: O 'O 9' fc ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft in
3.Well Use(check well use):
%:�.,1�.t . iZF.FI�T� -- C..,sF.l._:�- .'i.F tiY*1+rs:N y'�:t,.�zr"?:*'�•µ'r`^if;"<.� '�:,4";a�. :,:�\'::'.
Water Supply Well: FROM TO DIAMETER If SLOT SIZE THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) EIR6i'dential Water Supply(single) ft, fa In.-11
❑Industrial/Commercial ❑Residential Water Supply(shared) .l(4R pm"s.:.e.> ._ `y.:-.. ; tY.';{OWN L61; '^;u'
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
OLTi anon
Non-Water Supply Well: !� ' ft. 3 fr. orl`/
OMonitoring ❑RecoverY fL p' ft-
Iajection Well: fr. ft.
❑Aquifer Recharge OGroundwater Remediation •.zs •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
OAquifer Test ❑Stormwater Drainage
OEx eritnental Technolo ft ft.
p BY ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 'i; 9'�.bit "'_L� (�vL'='O'ls a"r iiiaa f`a"Is'isets;i" "�� ,t'v�,.,;:;Y•�,.;=�r;`�';-r_�
FROM TO DESCRDMON color,hardn 30111nek type,grain size etc.
OGeothermal Heatin Cooling Return 00ther(explain under#21 Remarks) tr. ft.
4,Date Well(s)Completed:U= 7-!Well ID# 'V �,d ft. ft
r
Se.Well Location: ft. ft. (JC`' 01
ft.
Y fr,
Tam -S AeA.AgI X }', d `7 > 9 S ft. fr
Facility/Owner Name Facility ID#(ifapplicable) --
ftw ft,
1 ,191 Ya u:Ic e �' ,�. ft ft.
Physical Address,City,and Zip
1g
Cowity Parcel Identification No.(PIN) i
GQ
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
35 �e2 41' N "83, Y-17 V8*9 w
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermaoent or OTcmporary
By signing this form,I hereby eerto that the well(s)was(were)constructed in accordance
�,,�� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7,Is this a repair to an existing well: ❑Yes or Ibit sO 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 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
F Number wells constructed: construction details. You may also attach additional pages if necessary.
For multiple innjection or non•water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: n (ft,) 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3@200'and 2 tr 100') construction to the following:
10.Static water level below top of casing: .'� (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: 6H (in,) 24b.For Iniection Wells ONLY: lr 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,
L13b.
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Yield(gpm) Method of test: Air lift 24c.For Water SuPety&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Nattual Resources—Division of Water Resources Revised August 2013