GW1-2021-06811_Well Construction - GW1_20210110

WELL CONSTRUCTION RECORD For Intemtll Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Mitchell Dean Cook F
ROM waTER zoivEs
OM TO DESCRIPTION
Well Contractor Name tfL ft.
ell
2043 ArtNC WeII Contractor Certification Nwnber :01<7TER CASTING for;miilte tased;wclla ORa1NER ffo` livable TO I DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. 6, ; ft. rt. y „ in.
Company Name 16;t:INNER CASING OR'f!)BI'O `eoiltie 4elboed
FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: //I � r%� It. f. in.
List all applicable well permlis(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 11:SC1tEEN ;: ♦,{
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft. tt in.
❑Geothermal(Heating/Cooling Supply) OR sidential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT.
❑Irri atlon 1 ft ;7 fL
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAYEI.FACIE•if a `Gcetile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETfiOntr. tr.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20:I)1tItiLING'`G043,attacti'iiddihonel' 'ehedta'if nei:esaa ,,:i'
❑Geothermal(Closed hoop) ❑Tracer FROM TO DESCRIPTION color,hardy soillreck type,grain size etc.
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fa
ft. ft.
4.Date Well(s)Completed:6 5.,-�7 J) Well ID# IV-/✓� ft. ft.
5a,Well Location: ft, (L
fa
Facility/Owner Name Fncility 1D#(if applicable)
ft. ft. J U N 1
Vinil
Physical Address,City,and Zip
21.BE1►4Al2KSv rra� �"•
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one ladlong is sufficient)
G;
N ✓%' 4�� ..?,..w `/'` G• W 'ems c!`' !7: 2 '
Signature of Certified Well Contractor Date
6.is(are)the well(s): q$ pmfianent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or qNo copy of this record has been provided to the well owner.
ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#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
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 construction,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: / f .Jr (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: .� Jam' (ft.)
Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Infection 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.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) L,/) Method of test: Air lift 24c.For Water Supply&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 healh'departinent of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013