GW1--06593_Well Construction - GW1_20241112

VI/1JL L.t.,ViN91.tWL 11UP1 ttnt..IJtt_i./to VI'-di 1 ror internal use unry:
I..Iitell Contractor Information: lit
DAVID F. COOK N.WATER ZONES - I I :
tccll Guntr ttor N crq ,,FROM TO DESCRtPtNN:
/7 ft. yQ ft. .4� ;.
CI S'/a
7, ft. ,do ft. JJ /2�
NC VYell Contractor Certification Number is t• as
15.bUT°ER"Crt,SINC(far mule-casetp eFetis)OR i.ti`I6[2(if ap ticabfe) .. .
DAVID COOKS PLUMBING FROM TO DIAMETER': ' THICKNESS 5LITERIAL
47 ft 7 fit-. a' .54 !o /. UL
Company Dame0611
L
--I IC INNER CASING Oft TUBING(seothat-Ina!rinsed-loop)2.V►'eli Construction'Permit ft: FROM i TO awntcTER+ THICKNESS MATERIAL
List altilpplicable well construction (Le.t1IC,County,State,Variance,etc.) It ft. 'in:
•
3.Well Use(check well use): Et. R; in:
Water supply Well:
17.SCREEN
FROM , TO LRAM ETER .'SLOT SIZE THICKNESS MATERIAL-
Agricultural D,L9ur' pat/Public 0,ft �cy•o R. �J in. �? r �� jGi3 fr,L
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) J ft. ft. /�► in �f J
Industrtal/Cotnntercial [Residential Water Supply(shared) ill GROUT
Irrigation FROM TO MATERIA►I 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fit. 0 IT. / i4, W d
lonitcring Recovery ft. sr ff.
njcction ih'ell:
ft. N.. .
Aquifer'eehatgo ndtvater-Remediation
19.SANDtGRAVEL-Pt1CK(If applicaD[e)`
Aquifer Storage and Redo ery Salinity Bonier • FROM- TO MATERIAL-. I-E:PLACEMENT METHOD -
Agwfer.Test Stomtwater Drainage 7! ft. /iJQ it. "6y u �jCu/
Experimental Technology bsidence Cizntroi fit ft. /'
Cerithermai(Closed In Trat r 20.DRILLING LOG(attach additional•sheets If necessary)'
Geothermal(Heating/Cooling�GOuIsn Return) FROi f TO DESCRIPTION(color,trardness,sofliroeL type.Frain sur,eta)g gMother(explain under#21 Remarks) -
t 0 ft. ft. '�f/7 j ;
4.Date Well(s)Completed: i t (4 j ¢#"-;( Well IDlt Et i Ci it' eJ`�' l
a.W ii Location: SSSi fit ! O d ft
It 1 pow ttowvio •%/ ft. / ft / f / l
.cllitylChvneiName Facility IN(if apptic-61 ,,fir ri. 0 ft. tejet:de sLIIIIT ;� Ittiv9 . 1 f— V t 9fY l �/ fL/4 fL Hi
-.•w.,,,..�.. YL 1 .tlJNOVPhyskaiAddress. tv,aadZit!! Et. ft. I' V V 2 �Q�
1
t✓. IKlX,1 c i't�i 21.RElV7ARKS
County Parcel Idertiticatioo Na.(PIN) ( ;,,r .j t;,x'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G `i t�
Of well field,one lavlongis sufficient) 22.Certificati • ^
6.Is(are)the well(s) . ermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cord fy that chi:wefi(s)was(were)constructed in accordance7.Is-this a repair to an existing well• QYes or 01‘ with ISA Nt'CAC 02C.0100 or ISA;'CAC 02C.0200 Well Construction Standards and thra a
i.
If this is a repair,fill out known well construction information and explain,lb.-nature olthe copy(wads record has been provided to the well owner.
repair under#21.remorls'secifonoran.the burl;of this form.
'23.Site,diagratnor additional welldetaiis:
B.For Geoprobe/DP':f or Closed-Loop Geothermal Wells:havingthe 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 welts construction details, You may also attach:additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface: /00 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fen-nnrftipfc.weirs fist tin depthsifdffferent(example Sa`200'end 24100)
construction to the following:
10.Static water level below top of casing: 42/ (ft.) Division of Water Resources,information Processing Unit;
If wpter keel is above casing,use" " 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter: ( (in.) •
24b.For Injection Wells: in addition do sending the form to the address in 24a
above,also submit one copy of thisiform within 30 days of completion of Well
12.Well construction method: /j'7 / 07(::. construction to the following:
(1,a,auger,rotary,cable,dimct push.etc,) / f
Division of Water Resources,Underground Injection-Control Prograiri,
. - FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce Inter,Raleigh,NC 27699-1.636 -
�13a.Yield(gpm) ./ Method of test: ".1.- 24c.For Water Supply•&.infection Wells: In addition to sending the form to
the address(es) above, also subunit totie copy of this form within 30 days of
13b.,Disinfection type: fir.“,•tt Amount: C . completion of well construction to the'.county health department of the county
{v1rrre corrstructrrf.
Fonts GW-I North Carolina Drimorr,ent of Environmental Quality-Division of Water Resources Revised 2-22-2016