GW1-2022-04091_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
DAVID COOK 14.WATER ZONES
Well Contractor Name /`, fL T 0 ft. DES B11
IPTION
4495A /mac
rL fL
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells)OR LINER art licable I
DAVID COOKS PLUMBING FROM I To DIAMETER I THICKNESS MATERIAL
ft. ft. i in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-1
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) H. IL is
3.Well Use(check well use): fL fL In.
17.SCREEN
Water Su Well:
Supply IA FROM TO DIAMETER SLOT SIZE THICKNESS MATERL
ft.
Agricultural QMunicipal/Public � ) IL in. v SC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in
— IndustrialJConuncrcial Residential Water Supply(shared) I&GROUT
11nigation FROM TO MATERM EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (� ft. �ft. mil, ,
Monitoring Recovery ft. fL
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage G ft. /j a.i ft. '00ai-
Experimental Technology OSubsidence Control fL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheers if nee
Geothermal(Heating/Cooling Return) F3Other lain under#21 Remarks) FROM To DESCRH`TlON color hordness,soturoc¢type,grain size,etc
�f ft. ft.
4.Date Well(s)Completed:4/5/2022 W,eS EN fit, fL
Sa Well Location: tt• , 1
BOBBY MCINTYRE fL 0 fL (2 F
Facility/Owner Name Facility ID#(ifapplicable) R' L) J R' L C S
1053 JUNIPER LANE JAMESVILLE, NC 27846 h• ,f N
Physical Address,City,and Zip
MARTIN 21.REMARKS APR I
County Parcel Identification No.(PIN) _
�a'� 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: M ''y
(if well field,one latllong is sufficient) 22.Certifi.Ca
N W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified 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: []Yes or x[]No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and chat 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#21 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
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drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (B-)
p 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) constriction to the following:
10.Static water level below top of casing: (it.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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
12.Well construction method: y�+ construction to the following:
(i.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: V u% 24c.For Water Supply&Injection Wells: In addition to sending the form to
L or the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ! r%!' `u Amount: 49 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 Revised 2-22-2016