GW1-2022-06151_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID FOSTER COOK 14.WATER ZONES
FROM to DESCRIPTION
Well Contractor Name
4495-A . Oft. oft. ,'
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells) R LINER if applicable)
DAVID COOK'S PLUMBING FROM TO DIAMETER THICKNESS MATERIAL
ft-
Company t. in. �z 5 G, L
Company Name 16.INNER CASING OR TUBING eotherm osed-loin )
2.Well Construction Permit#: FROM TO DIAMETER •THICKNESS MATERIAL
List all applicable urll construction permits(i.e.UIC,County.State, Variance•etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
17.SCREEN
Water Supply Well: FROM I TO DIAMETER I SLOT SIZE I 'THICKNESS I MATERIAL
Agricultural E]Municipal/Public ft. ft. in• G1 �� �/4� L
Geothemtal(Heating/Cooling Supply) residential Water Supply(single) ft. I ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
IrCi atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: nft. 5 ft. �� S
' v
T Monitoring _.. Recovery ft. ft.
-Injection-Welk-
Aquifer Recharge nGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier ' FROM TO MATERIAL EMPLACEMENT METHOD
'Aquifer Test [IStormwater Drainage 4 11- $ ft, v-� -
Experimental Technology Subsidence Control ft. ft.
Geothemtal(Closed Loop) ❑ITmcer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) fFRONTTo DESCRIPTION(rotor•h ness,soiVrockh e min sizC etc)
ft.4.Date Well(s)Completed: We►l ID# ft.
5a.WellLocation: ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. G ft. eo S
f� l fL << ft.
_f�
Physical Address,City,and Zip ft. ft.
21.REMARKS
County 1 i Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one]at/long is sufficient) 22.Certifieatio
N W t ;vslll A�t fi(Il. t5" V
6.Is(are)the well(s)iRlp"ermanent or DTemporary Signature of Certified Well Contractor Date
By_signing this fonn,I hereby cet4�rlrnt he scell s_s+ns(were_constnteted in accordance
7.Is this a repair to an existing well -E]Yes or 191N ivith 15A NC AC 01C.0100 or 15A NCAC 02C.0200 Mell Constriction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has Been provided to the well owner.
repair under#21 ren arks section or on the back of this.form.
23.Site diagram or additional well details:
3.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: / (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 1@100') construction to the following:
d
10.Static water level below top of casing: .; (ft.) Division of Water Resources,Information Processing Unit,
ffi ater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 _
11.Borehole diameter: (in.) n 24b.For Inie�Yells: 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/ / 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: 24c.For Water Suanh'&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!vine: C-� "�' Amount: completion of well construction to the county health department of the county