GW1-2022-01870_Well Construction - GW1_20220216

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- WELL CONSTRUCTION RECORD(GW-1) `r"°'� For Internal Use Only:
1.Well Contractor Information:
AVID FOSTER COOK 14.WATER ZONES i
'.,,k a�,i •s FROM TO DESCRIPTIO
Il�— Contractor Name y S ft. ft. �.
4495-A F E8 16 2022 a. G art.
NC Well Contractor Certification Number 15.OUTER ASING for IlicasedwellsOR LiNER if a tieable
DutETRDAVID COOKS PLUMBING ;rotiWzinq Unit, FROM E
I THICKNESS MATERIAL
Q+'ZOG (> it. % ft- l in. 5 c- 4/J U
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: FROM TO D R THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.) it• n• in.
3.Well Use(check well use): it. ft.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Pricipal/Public 0 ft. jt. in.
Geothermal(Heating/Cooling Conlin Supply) esidendal Water Su t Ch
( g pP y PP y(single) tt. it. in.
Industrial/Commercial DRcsidential Water Supply(shared) 18.GROUT I
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water S \ ly Well: v ft.
Monitoring 13Re ery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Re very Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage �� tt. ,� ft. ,� o L,/
Experimental Technol OSubsidence Control
Geothemial(Clos op) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRoat TU DESCRIPTION color,hardaess,soil/rock a rain size•etc.
ft. ft. S�7
" nate Well(s)Completed:�w v Well ID# ft• f ft c
WWellll Location:cao0n:
Facility/Owner Name Facility iD#(if applicable) (Q tt. J
1(I %211REMARkS
ft. ft.Physical Address,City, nd Zip
n ft•i � 6O n4i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification,
N W f �G.7AI
6.Is(are)the well(s) . Permanent or DTempoWo
Signs of Certified Well Contractor D to
By signing this ifi form,I hereby cerv ,that the well(s)was(were)c•onstnrcted in accordance
7.Is this a repair to an existing well: [:]Yes or with 15A h'CAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has heen provided to the well owner.
repair under#21 remarkv section or on the back ofthis.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.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
P /yL (h•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(example- @2 0'mid 2@100') construction to the following: G
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:_ _(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�J above, also submit one copy of this form within 30 days of completion of well
`\ Well construction method: .,/ construction to the following:
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) _ Method of test: ✓• 24c.For Water Suonh•&Iniection`Wells: In addition to sending the form to
// the address(es) above, also submit one 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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