GW1-2023-01001_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
DAVID COOK 14.WATER ZONES
Well Contractor Name
FROM
ft. TO DESCRIP N';ry ft.
4495-A
R. ft.
NC Well Contractor Certification Number 15.OUTER CASING for rtiiilti cased.wells OR LINER if applicable)
DAVID COOKS PLUMBING FROM TO DIA1tiETER FTHICKNJESS
MATERIAL
ft. ft. in. �!G ,a �,CJ
Company Name
`16ANNER CASING OR TUBING" eotherinal closed400
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well:
17:-SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural D unicipal/Public ft. ft. in, d �v Vt/
-Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERI L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D tt. ft. '� i
_ Monitoring ORecovery
lGeothermal
ection Well:
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL PACK(if a licable)
Aquifer Storage and Recovery Salinity Bamer FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test EIStormwater Drainage5Experimental Technology DSubsidence ControlGeothermal(Closed Loop) OTracer `20.DRILLING LOG attach additional sheetsifnecessaryFROM TO DESCRIPTION rotor, ardn soiUrock e, rain size,etc.)
(Heating/Cooling Return) Other(explain under#21 Remarks) V. �, ^"', t `G
C/ x.. P
I r6l (�( ft. ft.
4.Date Well(s)Completed: O V ell ID# 1-5 [�
Sa.nWell Location:
ft. . v ft. s
ft. ft.
• U�JI(� 1/l,�J 4nccma:i;,n f'facwa;n]UM
ft. E9
Facility/OwnerNamc Facility lD#(ifapplicablc) -f—/ �K 1t.
Mvm*CA � . f. f� .
Physical Address,City,and Zip
ft. ft.
�Q/VLy� Y 21.REMARKS .,.:..
County Parcel Identification No.(PIN) v• 1t 121
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Cerr ation• �y
N W L
6.Is(are)the well(s)Ox Permanent or Temporary Si rc of Cenificd Well Conuactor Date
By signing this form,I hereby cert fi,that the well(s)was(ivere)constructed in accordance
7.Is this a repair to an existing well: 0Yes or EjNo with 15A NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,.Tll out known welf construction information and explain the nature of the copy of tins record has been provided to the well owner.
repair under#21 remarks section at-on the back of this 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 constnfetion 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 ifdierent(example-3@200'and 2@1001 consttuctio6 to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If outer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �jtn.) 24b.Fdr Injection 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: d construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Ulk4erground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: , 24e.For Water Supply&Infection Wells. In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection tine: -e /Ca..✓Ae- Amount_ .1 Le, completion of well construction-to the county health department of the county