GW1-2021-02841_Well Construction - GW1_20210110

WELL CONSTRUCTION RECORD For Intam0l Use ONLY:
This form can be used for single ormultiple wells
1.Well Contractor Information:
Mitchell Dean Cook . -g 4 0. tx.4_, ::s:>s<<s- : ;:.,}, . Ys -
rl-
FROM TO DESCRUMON
Well Contractor Name ? ft ft
2043 A
NC Well Contractor Certification Number ?1`111 Will,/"$'/GY<:f
> .
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. -ft. fr.
Company Name 21' i I1?'.A IliJCy O. Crt 1'er a rl i' eft '.o =fse .� .< ,•r4 ,r'.
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: ;3 c> `�;Z I fJ ft. ft,
List all applicable well permits(i.e.Coun%State,Variance,Infection,etc.)
fA ft. in.
3.Well Use(check well use):
Water Supply Well:
FROM I To--
I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
OAgricultural OMunicipamblic ft. ft in.
OGeothermal(Heating/Cooling Supply) 6Nte-sidential Water Supply(single) ft' ft in.
Olndustrial/Commercial ❑Residential Water Supply(shared) ` -mH zr '. . .' f-`•=.fit.:ti''S is s. r,;� ' ;i t 'r,?
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon ft. } ft.
Non-Water Supply Well: '
OMonitoring ORecovery fa ! a '
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation
B.i" Rt Ia" bNwh":ti`"t:= }' 7=kr,k:i ,z7,, '%:::t•
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage tr. fr.
❑Ex erimental Technology to to
p gY ❑Subsidence Control _
OGeothermal(Closed Loop) OTlacer Qi .R I ' . , .....
FROM TO DESCRIPTION color,hal solUrock type,amin size etc.
OGeothermal (Heating/Cooling Return OOther(explain under#21 Remarks R, ft.
4,Date Well(s)Completed:C�`%- �• Well ID# ft. ft.
1V%// ,
ft. ft.
Sa.Well Location:
ft. fa
ft. ft.
Facility/Owner Namo. Facility ID#(if applicable)
ft. fa
"=JL L e �' { .^� f �3 tom'c�C' ft. ft. p• „ t
Physical Address,City,and Zip 7rnr.ESSIIi(�
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
7� N _ �y�yt) -x�
Signature ofCortificd Well Contractor Date
6.Is(are)the well(s): ®eermanent or ❑Temporary '
By signing this form,I hereby cerlo that the well(v)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and thm a
7.Is this a repair to an existing well: ❑Yes or 60146 copy of this record has been provided to the well'owner.
j'Ihls Is a repair,fill out known well construction Information and explain the nature of the
repair tinder#21 remarks section or on the back of thisform. 23.Site diagram or additional well details: .
You may use the back of this page to provide additional well site details or well
S.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 construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9,Total well depth below land surface: -0S (ft,) 24a. for A )Yells: Submit this form within 30 days of completion of well
For multiple wells list all depths J'different(example-3/@200'and 2@100') construction to the following:
10.Static water level below top of casing: ty 6) (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Centelr,Raleigh,NC 27699-1617
11.Borehole diameter: sa (in.) 24b.For Injection Wells ONLY: in addition to sending the form to the address in
Rota 24a above, also submit a copy of this,form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i
(i.e.auger,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
13a.Yield(gpm) J Method of test: Air lift 24c.For Water Suagly&Injection Wells:
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�6partment of the county where
constructed, j
Form GW-1 North Carolina Department of Ltnvironment and Natural Resources-Division of Water Resources Revised August 2013