GW1-2022-05004_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
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FROM TO
t`TO
FRR DESCRIPTION
Well Contractor
jNamme + t
t�1 / O r. � ft. fr.
NC Well Contractor Certification Number I&OUTER CASING Mir maltircmed wells:OR LINER if t ika '
,�,n FROM TO DIAMETER THICKNESS MATERIAL
1
IC+Y c✓�.�J 'I 1 �C C1 1/�-�-G� U rl�/ p ° ft 55 ft, is 5 0IM u
Company Name 16,INNER CASING OR TUBING'eotlrirnaf'elaud-list
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �I Z 03q—.10519 ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
it. fr. im
3.Well Use(check well use): 17.SCREEN.'.
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERIAL
i
❑Agricultural ❑Municipal/Public. ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 'IS.GROUT
FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
❑Irri O tion d ft fa c7�
Non-Water Supply Well: ^
17)
OMonitoring ❑Recovery 3 ft d f.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if avolkablel. '
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attgeh additio4al,sheets if '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRPTION color,h,odnes%sWilrock type, size eta
❑Geothermal(Heating/pooling Return) ❑Other ex lain under#21 Remarks tt ft
22 2�Z -N 0�- it ft
4.Date Well(s)Completed: Well ID# ft. (t
5a.Well Location: h O - ft ft.
MAY 1 wak COOK. ft. &
.11apility/ownerblarpe Nr Facility ID#(ifapplicable)
I �,Y fr. ft. t'QGt (Jfl�
(� ft ft.
Pal A essL tty,an � ���� ,y� � 21.REMARKS
TCounty`/►// ,ul Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce ation:
(ifwell field,one lat/long is sufficient)
—0?�
Signature of Certified Well Contractor Date
6.Is(are)the well(s):�rmanent or OTemporary By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or %rlh o copy of this record has been provided to the well owner.
If this 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 this form. 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 construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 5 5 5 (ft.) 24a. For Ail Wells: Submit this j form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@10o construction to the following:
10.Static water level below top of casing: (ft,) Division of Water Resources,Information Processing Unit,
1fivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells ONLY: 1In 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY LIS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: &— 24c.For Water Supply&Injection Wells:
Ir�� � r .
44 ii Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: V� 1+ Amount: 1 �' well construction to the county hei nth department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013

6/2/2021 ENV Health Permit t)`
Jackson County Department of Public Health.
538 Scotts Creek Road, Suite 100
Sylva, NC 28779 - Well Permit
Phone: [phone] FAX: [phone]
Reference Number: Permit Number: 2021-20330-9-10598
PIN: 7516-99-4572 Application pate: 1/14/2021
Owner: COOK, RONALD T City: CAPE CORAL FL
Address: 614 CORAL DR 21p Code: 33904
Lot Number: PUMPKINTOWN
` Service Type: IP,/ CA/OP/ Well Permit Bedrooms: 5
Directions To Site: pumkintown Rd to right on Chestnut Cove Rd. to hard switchback near end of rd.
site on left at switchback.
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EIS:
EHS: 9p1wx al Date:
Signature: Date:
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