GW1-2022-06762_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID FOSTER COOK 14.WATER ZONES
Well ContmctorName 111 TO DESCRIPTION
4495-A 3 Sift. j
ft. Ct.
NC Well Contractor Certification Number
15.OUTER CASING for mulli-cased wells)OR LINER(if a livable)
DAViD COOK'S PLUMBING FROM TO DIAMETER THICKNESS MATERIAL
ft. 9)G� It. in.
Company Name r�(
16.INNER CASING OR TUBING( eothermal closed-loop)
2.Well Construction Permit#: FRODS TO DIAMETER THICKNESS MATERIAL
List all applicable nrll construction permits(i.e. UIC.Counn,.State•Variance.etc.) R. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
(�—� FROM TO DLAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DM icipal/Public j—ft. 3� tt. in. �c+ se C�L41 L 7 i�
NGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
fiTigation _ FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
-- nitoring
�- Reicotv ety-
econ Well:
fr - —--
Aquifer Recharge Groundwater Remediation
fe 19.SAND/GRAVELPACK(if a livable)Au Storage and Recovery•"✓„j' DSalinity Barrier FROM TO MATERIAL EMPLACEMENT Aquifer Test `�y,. Stormwater Drainage t ft. 'U it.
_ �. S
Experimental Technology "--- --QSubsidence Control ft.
Geothennal,(Closed Loop) Evff z:er 20.DRILLING LOG attach additional sheets if necessar•v)
Geothermal(Heating/Cooling Retum) _ Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type.gain size,etc.)
ft. ft.
4.Date Well(s)Completed: I °' Well ID# ft. , fr. '— ' -Jr
J'
5pa.(Well L{'ocatie�n:
1v
_ l��X�
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Uttar, .
W�. �.oOA �V1��N it. ft. � �.�..
a
Physical Address,City,and ILip J ft. ft.
21.REMARKS Jul 13 ,
County Parcel Identification No.(PIN)
rl�r,r•n s,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(ifwcll field,one lat/long is sufficient) ' '(-` ) �(i�•CJv)i 7�1,7 J\I 22.CertificatioCertified:
N W
6.Is(are)the well(s)E(Permanent or [DTemporary Sienatur of R'ell Contractor Date
By-signing this form,77ierebj'certify-lJiat dte xell(sJ was(were)c•onslru ted in accordance
7.Is this,a repair to an existing well: 0 Yes or c No tiitlt 15A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard.?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 tinder#21 remarks•section or on the back ofthis 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 ;oitstruction details. You may also attach additional pages if necessary.
drilled:
r.'1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the folloveine:
10.Static water level below top of casing: (ft.)' - Division of Water Resources,Information Processing Unit,
lfxater level is above casing,use" " 1617 Mail erv' Raleigh,NC 27699-1617
IL Borehole diameter: (/ (in.) 24b.For Iniection 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: /Z'!L & `'- construction to the following:
(i.el auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Prograpt,
FT WATER SUPPLY WELLS ONLY: 1636 Mail Service Cehlel•,'Aaleieh,NC 27699-1636
Yield(gpm) ;/5 1
4 hod of test: v1-11 24c.For Water Supply&c Iniection Wells: In addition to sending the form to
the addiess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hve: ��w Amount: 3 06 completion of well construction to the county health department of the county