GW1-2022-01489_Well Construction - GW1_20220126

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
(@( -AVID FOSTER COOK 14.WATER ZONES i
.i Contractor Name FROM TO DESCRIPTION
ft. 5—ft.
4495-A J
t7 ft. `g ft. y 9 I
NC Well Contractor Certification Number 15.OUTER CASING for mWG-cased wells OR LINER if a lieable
DAVID COOKS PLUMBING FROM, TO D IETER IM ESS MATERIAL
ft. ft. in. J
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 1t• ft. in.
3.Well Use(check well use): Ct. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Ptiblic ft. !VC.
. in. `/ L
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in. 7
Industrial/Commercial oResidcntial Water Supply(shared) 18.GROUT
IITi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply is Oft' �1t.
i
Monitoring OR very
w Injection We"gySubsidence
ft. ft.
Aquifer Reundwater Remediation
19.SAND/GRAVEL PACK if a Hcable
Aquifer Stonity Barrier FROM TO MATERIAL. EMPLACEMENT MF,THOD
Aquifer Tesnnwater Drainage • C ft. L `,ft. . w/
Experimentsidence Control ft. ft.
Geothermalcer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION cobr,hardness soil/ruck type,grain si etc.
A mate Well(s)Completed: Well ID# ft, ft. t
Well Location: 1( `�
• l� l&A 1 �V�Lv' ft' ft.
Facility/Owner Name Facility ID#(if applicable) ft. V ft• rs7�
Physical ddress,City,and Zip �j QQ f�(�' ft. ft. w'
CountI� O� ✓ �31 I DD 21.REMARKS
y v Parcel Identification No.(PIN) :4
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or DTemporary Ktgnat4Kof.Vcrtificd Well Contractor Date
By signing This arm,I hereby cert fi,that they wells)was(were)constructed in accordance
7.is this a repair to an existing well: Yes or r No
with I5A NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of 1W farm.
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.
drilled: Jay SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4/y 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i(different(example-3@200'and 2@100') construction to the following
10.Static water level below top of casing: A (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b.For Injection Wells: In additionfto sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
Well construction method: constriction to the following: j
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)'7"` Method of test: J-` 24c.For Water Supply& Iniection Wells: In addition to sending the form to
r the address(es) above, also submit orie copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Ditision of Water Resources Revised 2-22-2016