GW1-2022-09874_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For luternal Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook d4 .w,ATEV..gNES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2043 A °� zf
7D�r` 5 71 ft
NC Well Contractor Certification Number 15 QUT•PR-GAS71VG for.ilfi@ rc6scd!weUs,Of2li1NER,tf." livable <'':
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. o fr rt
Company Name D t' G
ER CASINr OR]USING' 'eoihermnitcloJed-too %_
FROM_ TO DIAMETER THICKNESS MATERUL
2.Well Construction Permit#: U�� 7.7 1 -� _ ft -'--
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
3.Well Use(check well use): ft. ft, in.
17 SGREFN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MAT
ERIAL
DMunicipallPublic tt, fr. in.
❑Geothermal(Heating/Cooling Supply) Q�sidcntiat Water Supply(single) ft• fa in.- -
❑hidustrial/Commercial OResidential Water Supply(shared) 0.
18.GROUT;
FNon-Water
FROM TO MATERIAI, EMPLACEMENTMETHOII&AMOUNT
Supply Well: ft• 5 ft' /fir /�� �g ❑Recovery tt fLell: f ft.
charge ElGroundwater Remediation 'orage and Recovery ❑Stllhtity Barrier FROM TO MATERIAL EMPLACEMENT METHOD '
ft. R.
iJAquifer Test ElStomtwater Drainage
C1Experimental Technologyft. ft
[]Subsidence Control
a:20 DR111}IN(r Gh4'atfaclfiufdtttoaal'sfi fE�s it3u``es�e
OGeothermal(Closed Loop) G11•raCer FROM TO D&SCRIPTI4Neolorbardoeat,soiUrockt rain�izectc. '
❑Geothermal Heatin Coolin Return) UOther explain under421 Remarks) tt. fa
ft. ft.
4.Date Well(s)Completed: /p-/--)_1a Well ID# ii/��_�•�
ft. ft.
Sa.Well Location: - ; ;=--
M `I' G '' •�s cF Nam R
Facility/OwnerNanue Facility lDif(if applicable) ft ft. -OCT-2 8 211L
ft. ft Itliiiil:�„tDO i'i%C.;c.^ ljirF
Physical Address,City,and Zip '2l REI4IAR1(,;.,.. �' -'�
L 1
6o �'1��s� �u
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary
By signing this fonn,I hereby nett fy that the well(i)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC'AC 02C.07.00 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or M_0__ copy of this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or at the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8,Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same constuction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �,� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple wellslist all depths ifrlifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: /SQ (ft.) Division of Water Resources,Information Processing Unit,
ljwater level is above casing,use"1" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole.diameter: 6" 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 bays of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.uugm',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
Air lift 24c.For Water Supply&In•ectioD Wells:
13a.Yield(gpm) � Method of test:
— •'—' Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H & H Amount: 12 oz. well construction to the county health department of the county where
constructed.
Forul OW-1 North Carolina Department of 1?nviroument and Natural Resources-Division of Water Resources Revised August 2013