GW1-2022-01937_Well Construction - GW1_20220224

W.ELI,CONSTRUCTION RECORD
This form can be used for single or multiple welts For Intemal Use ONLY:
1,Well Contractor Information:
Mitchell Dean Cook Wy a
FROM 7'0 DESCRDPTION
Well Contractor Name ?t. tft.
2043 A ft. ft.
NC Well Contractor Certification Number 15 Q.UT$R"SIN forrmi tr ebb <<YEtIe?Qft.UiNE 22p,
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. r rr tft -t Company Name 1 ;en
6 rSGT $
miit'NuieiUl h %q: "e G
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#:— ft• ft, in,
List all applicable well permits(i.e.Courl.Stare, arlance,Injection,etc)
3.Well Use(check well use):
r
Water Supply Well: FROM TO DIAMII SLOT SIZe I THICKNESS MATERIAL. ,
C1Agriculhiral DMuni 'pavpublic
DGeothermal(Heating/Cooling Supply) sidential Water Supply(single) rr.
Dlndustrial/Commercial ClIkesidential Water Supply(shared) 1S.C�RnUT ;... i.:, !
-3 alien
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
� • it. �.,O ' fr. v 7�
Non-Water Supply Well:
DMonitorin ft. ft.
g DRecovery
Injection Well:
DAquifer Recharge DGroundwater Remediation I—.. ;D!(I `YFI?.hG1e f A licglile ,
❑Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL I EMPLA CEMENT METHOD
fr, ft.
OAquifer Test DStonnwater Drainage
fL fill
Technology ❑Subsidence Control
DGeothermal(Closed Loop) DT•racer -2Q.nR ='LTNc LhGa atfir6tlih'dihoualitflreiita`•i "3a ;� '`.,
FROM TO DESCRIPTION color hardu soil/rock typl,grain slue etc.
DGeothermal Hearin Coolin Return C1Other(explain undertl2l Remarks) R. fa
ft, ft.
4,Date Well(s)Completed:0,A-eZ/- .Well IDN Af, /
ft. ft.
Se,Well Location: �-- ft. iL FEB 2. 4 202?
_ez n es 7, za All /soh
Facility/Owner Name Facility lD#(if applicable)
ft fr. c
Q�rk ,ei 1Q1�f�S y 1 1/9 zer-I �Gs and ft. ft. 1
Physical Address,City,and Zip
21.<REMARIC,
Comity Parcel identification No.(PiN)
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one let/long is sufficient)
9P� N q-3 IQ 18 . o W � Ian lfee4 o�
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ermanent or ©Temporary
By signing this form,/hereby cart fy that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A Al 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ©Yes or .No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the backgjthisform. 23.Site diagram or additional well details:
You may use the back of this page tolprovide additional well site details or well
S.Number of wells constructed: conshuction details. You.nhny also attach additional pages ifnecessary.
For multiple injection or nornwater supply we11s ONLY wish the same construction,you can
submit one form. SUBMITTAL"INSTUCTIONS
9,Total well depth below land surface:p y- n' s� (ft,) 24a. For All Wells: Submit this foim within 30 days.of completion of well
For multiple wells list all depths tf different(example•3@200'and 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 rasing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (ia.) 24b. For Injection Wells ONLY: Iii,addition to sending die 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 Centr,Raleigh,NC 27699-1636
13a.Yield(gp m) Method/ Air lift 24c.For Water Supply&Infection Wells:
fQ r
�" -- 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'department of the county where
constructed. .
Form(;W1 North Carolina Department of Euviroumcat and Natural Resources-Division of Water Resources Revised August 2013
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