GW1-2022-04093_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: B
1.Well Contractor Information:
i
DAVID COOK 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4495A
/0 ft ft 1'14ChkAA
ft. 5— it. lt!'<7 I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
DAVID COOKS PLUMBING FROM To DIAMETER I THICKNESS MATERIAL
a fL It. , in. I <
Company Name 16.INNER CASING OR T BING(geothermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,County.State,Variance,etc) ft. it. rn
3.Well Use(check well use): it. fL in.
17.SCREEN
Water Su Well:
Supply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- Agricultural DMunicipal/Public � t. _X) ft. in,` U sPC,7 YLt
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in
Industrial/Commercial DResidcnfial Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERLALL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. S'ft.
Monitoring y Recovery ft. fa
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
_ 19.SANDlGRAVEL PACK rf a licable_
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
- Aquifer TestStormwater Drainage _ ZI G ft. �lr v ft. a b
Experimental Technology Dsubsidence Control It. ft.
— Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION coat,A tau aoiVrock ill svc,etc.
4.Date Well(s)Completed:4/512022 Wen ID# R. ft
5a.Well Location: ft, 4'I
BOBBY MCINTYRE 1117
Facility/Owner Name Facility ID#(ifapplicablc) ft. ft.
1053 JUNIPER LANE JAMESVILLE, NC 27846 ft. ,=� J�J-J,, "
Physical Address,City,and Zip R, it.
MARTIN 21•REMARKS APR
County Parcel Identification No.(PIN)
.;� ��I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: }t r�
(if well field,one IaUlong is sufficient) 22.Cerhfiea
f
6.Is(are)the well(s)E)Permanent or OTemporary 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 )No with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that 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 additionsl 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-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: (fL) 24a. For.All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top.of casing: 0L) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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: �U f �" 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) 5 Method of test: L' 24c.For Water Supply&Iniecti n Wells-, In addition to sending the form to
hr the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type 6_4_u Amount: 49 O completion of well construction to Ithe county health department of the county
where constructed.
Form GW-I _ North Carolina Department of Environmental Quality-Division of Water_Resources Revised 2-22-2016