GW1--06595_Well Construction - GW1_20241112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID F. COOK 14.WATER ZONES ;
Well Contractor Name FROM TO I DESCRIPTION
4495-A . 9/ ft' 90 ft. . -O4
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(ifap licable)
DAVID COOKS PLUMBING FROM TO DIAMETER' THICKNESS MATERIAL
ft- 9® ft- I 'in- ,st� o A,
Company Name /�O Mn 16.INNER CASING OR TUBING(geothermal
2.Well Construction Permit#: ! (1/0 FROM TO DIAMETER! THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I is
3.Well Use(check well use): ft- ft. tn'
17.SCREEN
Water Supply Well: I FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural cipal/Public ,g,ft, 90 ft. fg in.1 rpm S44 y"
..
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) P . R. m, a!
Industrial/Commercial EjResidential Water Supply(shared) 1&GROUT l
litigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,, c ,�►
ft /' �+ fL obeivf
Monitoring ORecove , ft ft.
Injection Well:
ft ft.
Aquifer Recharge _ Ili roundwater Remediation
•19.SAND/GRAVELPACK(if applicable) -
Aquifer Storage and Recovery oSalinity Barrier FROM To MATERIAL . EMPLACEMENT METHOD •
Aquifer Test D Stormwater Drainage 0/ft- 50 ft' r 71 / /64:-P
Experimental Technol Subsidence Control ft ft. f
Geothermal(Close oop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION or,hardness,soil/rock type,grain size,etc.)
1 {y/�, et ft. .9 ft. (7,S�
4.Date Well(s)Completed: `I t
v' a"I Well ID# �i ft. P/t4 ft. I
• 5a.Well Location: �•�P D' -5 Q ft- '$•,.
N 1V ' Cw s ft'
ft. 4/ 1.
Facility/Owner Name Fa y ID#Of applicable) ft. f6'<. ft. e•4,
1+1 C/p(1- C O J Q VJ O f i1I/1( 4 f- 70 ft.
Ph3rsical Address,City, d Z ++jg)/�j j ` ,l ', r^
��T7(;j •�A ]i� � 21.REMARKS I ,
C �4Ji/0/I County Parcel Identification No.(PIN) ; NOV 1 2 2024
4 ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1:.`_"'_' " ..
(if well field,one lat/long is sufficient) 22.Certification' 1`' `•
'.
N W ', /`Al f,
6.Is(are)the well(s) Permanent or Temporary Signatu f Certl$ed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accotrktnce
7.Is this a repair to an existing well: DYes or Etio with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in formation and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
B.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 construction details. You may also attach additional pages if necessary.
drilled SUBMITTAL INSTRUCTIONS it
G�
9.Total well depth below land surface: d L5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'mid 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 769 9-16 17
11.Borehole diameter: 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
r above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: t* a1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:_/041 24c.For Water SUDDIv&Injection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 0 ••tr Amount: ev.° ` completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ' Revised 2-22-2016