GW1-2022-04191_Well Construction - GW1_20220419

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
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1.Well Contractor Information:
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')AVID FOSTER COOK 14.WATER ZONES i
'Contractor Name FROM TO DESCRIPTION
ft ft.
4495-A v ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased w R OR LINER if a Gcable
DAVID COOKS PLUMBING FROM To DIAn R I Talc S MATERIAL
ft. ft. in. �`
Company Name 16.INNER AS1NG OR TUBING eothermal closed too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.VIC,Counq,,State. Variance.etc.) ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Su Well:
Supply FROM TO DIAMETER SLOT SIZE TIII ESS MATERIAL
Agricultural 0rRcsiticritialWatcr
nicipal/Public ft. it. _ in. S tjGeothermal(Heating/Cooling Supply) G Supply(single) ft. n. in.
Industrial/Cornmercial DResidential Water Supply(shared) 18.GROUT
Irrization FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring pRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stotmwater Drainage ft. ft. 0.0--
Experimental Technology OSubsidence Control n• ft•
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnM soiltrock type,grain su.etc
4.Date Well(s)Completed: t/ Well iD# ft' L C
✓ell Location; n• S ft. C l�
Facility/Owner Name Facility iD#(if applicable) ft. ft.
( I G 0 ft. ft. r ✓
Physical Address,City,and Zip ft. ft.
:*E
mu�i
I/"1 21.REMARKSC �/ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: PmcwAing Uil k
(ifwcll field,one tat/long is sufficient) 22.Certifieado
N W
6.Is(are)the wells) Permanent or-Tempo
gna Si ertified Well Contractor Date
or-Temporary - --
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes ofNo with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standardv and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OP 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 10 'and 1Q100� 1
� construction to the following:
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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 27699-1617
11.Borehole diameter:�� (in.) 246.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
t Vell construction method: construction to the following:
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) Method of test:—,r 24c.For Water Sup
nly&Injection(Wells: In addition to sending the form to
Ile address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type a d'r b Amount:
Q� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016