GW1-2022-06157_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
DAVID FOSTER COOK 14.WATER ZONES
FROM TO DESCRIPTIO.'l
Well Contractor Name
rsr ✓G
4495-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
DAVID COOK'S PLUMBING FROM TO I DIAMETER THICKNESS I MATERIAL
0 fit. ,70 ft. I ,
Company Name
i 16.INNER CASING OR TGB[NG(geothermal closed-too
2.Well Construction Permit l+r: FROM TO DIAMETER THICKNESS I PLITERIM
List all applicable itell construction permits(i.e.UIC.Counq•.State, Variance,etc•.) it. ft. in.
3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: FR01t TO DIAMETER SLOT SIZE THICKNESS AfATF.RL1i.
Agr icultural E] to aVPublic (c. r.-fit. in.
Gethenal(Heating`Cooling Supply) csidential Water Supply(single) ft. fit, in.
OResidential Water Supply(shared) 18.GROUP
Nlnd,), nist .'vCoinmcrciaI
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOV-1T
)Son-Water Supply Well: ft. ft.
Monitoring DRecovery
Injection Well:
ft. fit.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPL.ACF.\IENT METHOD
Aquifer Test O3Stontnvater Drainage ft. u ft.
Experimental Technology OSubsidence Control
Geothenual(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION lor.hardness,soillrock is e.••rain size,etc.)
HGcotherinal(Heating/Cooling Return) Other(explain under aZ I Remarks) ft. / ft.
4.Date Well(s)Completed: t! Well ID# ft. � fr.
ed fit. ft. ,
5a.Well Lt)Cation: J
" fit. �
L
'Faccility/OwncrNhc FaFacciilliinn,ID#(ifapplicable) fit. ft.
V4�� 1�-)VIA l�l/l� Vll\�iN'/UY�• IW V'� .�VK. fit. fit.
PhvsicaI Address,City and Zip ft. fit. N 2
Vn 21.RE1r_4RKS
County Parcel Identification No.(PIN)
t-!'}jJ.'✓k'j,.��.,�"u'J'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: UN(,i
(if welt field,one laviang is sufficient) 22.Certification
1 W tw=
6.Is(are)the well(s)O Permanent or Temporary Signal e`ot Cenfi al3 all nractor`" —gate
Av slgnning rhu'bnn.1 hereb"r certiii-that the tve11W was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or :'o ,with 15d NCAC 01C.0100 or 15A RC4C 02C.0?00(sell C'onslntction Siandan&and their a
if this is a repair fill out knDIM}refi construction infbrnuaiion and explain the nature ofthe cups'ofthis record has been provided to the well owner.
repair under»?I r•einarks see-lion or on the back bfthis fibrin.
23.Site diagram or additional well details:
S.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: V V (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJjereat(example-3@200'and 2!A 100') construction to the following:
10.Static water level below top of casing: /t- (ft.) Division of Water Resources,Information Processing Unit,
i )rater level is above casing.use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: '/ (in. 24b.For Injection Wells: In addition to sending the form to the address in 24a
J�r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4`2 t� construction to the following:
(i.e.aueer,rotary,cable,direct push,etc.)
Division of Water Resources,Utdderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test; 24c.For'Water Supply&Injection Wells: In addition to sending the form.to
l _ / the address(es) above, also submit,;one copy of this form within 30 days of
.•..- r____c__.x__ /l/.!.. ' '-'__._.. )9 nn I'rinn of ,,,It .•r..,'tn„ tL.., t.. ill, 'r nt..I—Ith ri—t—f of thA rnunn.