GW1-2022-06842_Well Construction - GW1_20220720

Well Contractor Inrarmution:
DAVID FOSTER COOK —
Veil Comictur Aaac FRci�l 7.n
.. — -nE:.i uli•rirj.
IC Nell Cwdmctor Cernlicatioo 14u W,,r
1",.Ol'rF.R C•%sixn for mulll-ca,cd hells OIt LI�Jt R okra licab%)
DAVID COOK'S PLUMBING F7tu>I ro pL��f17FR —I TIitrkxl.�s
'umpany'Name �Ll—
I6.I%NLIt C'.kSIXG OR'I'l INNG fecntl+crn+al rtmcd-Inn r
lVell Construction Permit If: I ROM bLt11FTr.R floc I(N!�5 1i(IF AI tL
ist&I g0icchle r+rl1 a+rn'rue:tion pernrirs ri e U'/C.Counrj•,5rrrte,i•arianee,c•rr 1 ft. (l, in.
%Veil Ilse(cheek itch use): ft• ft. in.
Voter Supply Well: iT.SCREEN
1110N to —bl•i�1F-TrR 51_07 S17..F 711 IC 6AF nS uvrF RIAI,
jAgricullural Q ,nicipaUl'uUiic UQ. ;J ft. Ea. - 0.
4 v
)Geothermal(1leatinglCoolmgSupply) [ /Residential WaterSupply(sing(c) � --
jindusinatiCommercial []Residential Water Su f[. ft. all.pply(sltand) 1&GROI.f _ --
liri Linn MUM to 11ATFRt%L I?S1rI=10E.}S Eli'1 lIF.rHUn&•11inL'�P
inn-%Voter Supply Well:f ft. 0 ft.1Ionitoring Recovery ft. n.6:�tlA�
ijection Well.
--iACjd er f Rectiaigc —routri di
dwater Rcmcation - - R• ._ ._ n._ -
19.SAND/GRACRL PACK ;t'a ticahlri
IAthtltefSinidge CCOVCry [:)SalinityRarrier MOM Tel Mt Ell I%1. f:MMA(.F.\t1.At•atitlEUI)
iAquil`crTest []5torrawalerDrainage r v ft. � R.
lLxperimenta� Inolegy Su a1$ icTicc Control
iGeuthennal(Closed Loop) []Tracer ZQ.DR11.L1'N'C7 LOG nituch irddilianal sheets if ercessan
—
IGeuthermal(Ifratin C)osin Return) _ ON:r(ex lain underh2l Remarks) FRU�Ir 15 n1:SCR+ET)UV(cnbr,hanlntt�selr.�►+one, n;,,vc,a�.
.Date Well(s)Completed: ( ( V Well Will R• f4 J
L Well Location: ft. J rt.
DVE '7:d1tPw.tAi
xility'Owner wane Facility IID#(if applicable) ��[J n �t�/ ft.
562 NC L1 b1
iys"Address.City,and Zip / ft. ft.
r 1 +1� 2 t.REMARKS
n,aty Parcclldent7 ification:ya.(I'1N)
'w�;�,"bllihq
i.Latitude and longitude In degrees/rtanutes/seconds or decitual degrees:
'walk fiohL ow IWIting is sofficieni}
12.Ccrtificatl
'Js(are)the n•ell(s)opermaneut or ❑Temporary SigatutcofC tifial\vr)l(nnlcatcu Dale
By aignmg thin jurm,!hereby cerrify'hut the m•lldl uv.r 6! a tmolnNir-/in mxvrdasre
is this a repair to an existing well: Q Yes or No with/S4 A'C.�C 0?C'.OIRO ur 1Jd+VCnC f,:C,.OIfiO IYr/l Cnnnr.+rona Sranrlards and that n
lei,is a repair,fdl uut btn,.d»ril eosttaaaYion tnjrmta'iun and e.Yplain the aahrrr oflJre cul3'^jrhu record has hcxn prrrs'rded'o the null onner.
Wr nndrr# 1 remarks section or on rite tact u/title form.
23.Site diagram or additional well details:
ror Geoprobe/DPT or Closed-Loop Geothermal W01e having the same You may use the back of this page to provide additional well site details or%yell
nstruclion,only 1 GW-1 is new. indicate TOTAL NUMBER oNveits construction detail^. You may also attach additional pages if nct=sary.
(11ec1:
SURNlI'1TAL INSTRUMONS
Total well depth below land surface: (it•) 24a. Eor All Welln Submit this Conn within 30 days of completion of well
tu
rmultiplearitrt all depthsifdircrewema la-3,Q-200'ur.42(4I001 construction[o the fallowing:
.Slatic stater level below top of caslog: J (ft) Division of\Vater Resources,fnformat(an Processing Unit,
pater Intl u ahow•emirtg,use,..r^ 1617 Mail Service Center,Ralef-h,NC 27699-1617
Borehole diameter: (in. 24b.For infection Wcl15: In addition to sending the form to the address in 24a
above, also submit one copy of this furl within 30 days of con letion of well
Vcll construction method: �" construction to the following; p
v uger.rutary.cable dimct push,etc.)
Division of 1Vater Resources,Underground Injection Control Program,
111 WATER SUPPLY WELLS ONLY: 1636,Stall Service Center,Raleigh,NC 27699-1636
R.Yield(gpni)�7 Method of test: 24c.For Water Supply—,Ti.Iniection\�^cols: In addition to sending the Corm to
the address(cs) abov also submit one,copy of this Rom-within 30 da}s of
b.Distnfectioa tsne: — /'J e,A..ta� Amount: 6 completion of wiziI construction to the county health dcpartmcm of the county
I