GW1-2021-07643_Well Construction - GW1_20211201

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells For Internql Use ONLY:
1.Well Contractor information:
Mitchell Dean Cook UR,
FROM TO DESCRUMON
Well Contractor Name 39- S" 33,6,, ft-
2043 A ft. &
NC Well Contractor Certification Number FROM TO
DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. f
6 L EZ3 J ft 6" In. sq&-.z
Company Name __5
_57toxffl
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: ft. ft. lin.
List a//applicable well permits(i.e.County,State, Variance,Injection,etc)
ft ft. in.
3.Well Use(check well use):
. ............. ........
Water Supply Well: FROM I TO DIAMETER. ! - I SLOT,SIZE I I THICKNESS I I I MATERIAL
OAgricultural omunicipawublic ft. I ft. Ia. I I I
OGeothermal(Heating/Cooling Supply) PRe—sidential Water Supply(single) ft. ft. in. It
01ndustrial/Cornmercial EIResidential Water Supply(shared) FROM TO
I 01rriRation J MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water i �8 u p p_1yW e 11: ft. 3 f'--0 O- itr, ORecovery ft tcl -Z-Aep 6,-V.,*,,e,
Injection Well: ft. ft. _5
OAquifer Recharge OGroundwater Reniediation
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL F.MPT-AVVA�I -ETHOD
ft. ft,
[JAquifer Test OStormwater Drainage
OExperimental Technology (DSubsidence Control ft. ft.
1094 OGeothermal(Closed Loop) 0Traccr FROM TO DESCRIPTION(color,biminess,301frock type,smin'size.etc.)
OGeothermal(Heating/CoolinR Return) 00ther(explain under#21 Remarks) fr, fa
4.Date Well(s)Completed: ZL12_-_2_L well IDN IA ft.
Sa.Well Location: ft. ft. RR; F r
ft. ft ULE 0 1 7fl7l
FacilitylOwnor Name Facility ID#(if applicable)
Allh 2
Physical Address,City�and Zip e I./- ft. ft. 4.
Cotuity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fatilong is sufficient) 22.Certification:
NA 4,6 4_51 71,
6.I&(are)the wel1(s)- gpetmanent or OTemporary Signature of Certified Well Contractor Data
By signing ibis form,I hereby cer16 that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: 13Yes or WNa— copy of this record has been provided to the well owner.
111hts 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:
8.Number of wells constructed: You may use the back of this page to provide additional well site details or well
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: (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'and 2@100') construction to the following:
10.Static water level below top (ft.)casing. Division of Water esource 1 9,Information Processing Unit;
if water level Isabove casing,use , 1617 Mail Service Center,Raleigh,NC 21699-1617
11.Borehole diameter: 6" i
(in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this(form-within 30 days of completion of well
12.Well construction method: Rotary t
construction to the following:
(i.e.sugar,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t<lj Method of test: Air lift 24c.For Water Supply&Injection Wells:
H & H Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 12 oz. well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013