GW1-2022-04190_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: E
i
1.Well Contractor Information:
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DAVID FOSTER COOK 14.WATER ZONES
II Contractor Name FROM TO DESCRIPTIO
J ft. J ft.
4495-A
NC Well Contractor Certification Number 5.OUTER CASING for multi cased wells OR LINER a livable
DAVID COOKS PLUMBING FROM TO DIAMETER( TIHCKNESS J I MATERIAL
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Company Name
16.INNER CASING OR TUBI G(Peother at closed-loo
2.Well Construction Permit#: Jl p p 9 7 77 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CounO{ tare, ariante;a 07) ft. ft. in.
3.Well Use(check well use): kftwaw pmawshv WIN ft. tt. in.
Water Supply Well: 17.SCREEN
Pp Y FROM TO DIAMETER !SLOT SIZE THICKNESS I MATERIAL
Agricultural tc'pal/Public t. ft. is J J vv
Gcothemial(Heating/Cooling Supply) Residential Water Supply(single) tt. ft. in, j
Industrial/Commercial DResidenfial Water Supply(shared) IS.GROUT
Irrigation FROM TO MATE ,EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. v ft'
Monitoring ORecovery ft. ft.
Injection We
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)__
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMEN ETHOD
Aquifer Test DStonnwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(ex lain under#21 Remarks) JF�RMTO DESCRIPTION color barrio soilfrock a in size,etc.4.Date Well(s)Completed: u Well ID# ft'
A*eH Location: y ft.
«. e
Facility/Owner Name Facility 1D#(ifapplicable) h.) ft. Q ft. L'
A!n ft. ft. d. s
Physical Address,City,and Zip �� ft. ft-
N1 21.REMARKS
County L Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one lavlong is sufficient) 22.Certifieatio
N W J1 w
6.Is(are)the well(s) Permanent or Temporary
SignffirKofCcrtificd Well Contractor Date"
By signing this farm,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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#11 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / J SUBMITTAL INSTRUCTIONS
9.Total.well depth below land surface: Atr✓i (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJjerenr(example-3@200'and 2@1001 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: (in.) n 24b.17or Infection Wells: In addition to sending the form to the address in 24a
Q /l above,also submit one copy of this form within 30 days of completion of well
� Well construction method: U✓ construction to the following:
.�.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'' 24c.For Water Suppy,&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: (2 ` Amount- d Z. completion of well construction to the county health department of the county
where constructed.
Form GW-1 p North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016