GW1-2022-06578_Well Construction - GW1_20220708

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wen Contractor Information:
I
DAVID FOSTER COOK 14.WATER ZONES t
FROM TO DESCRIPTIO
Well Contractor Name �"3 jv j�{6 ft.
4495-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(Hap licable
DAVID COOK'S PLUMBING FROM TO DIAMETER TRIMNESS MATERIAL
' S e) ft. )41- ft. in. % t/U •_
Company Name 16.INNER CASING OR TUBING eothermal closed-lop
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL,
List all applicable well construction permits(i.e.UIC.Coun0%State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. In
Water Supply Well: IF7R.OSM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 nrcipaVPublic j_ft. j�' F in. J s
Geothermal(Heating/Cooling Supply) sidential Water Supply(single) ft. ft. in.
RIndustrial/Commcrcial DResidcntial Water Supply(shared) 18.GROUT
krigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Welt / tt. �} rL dim
_ Monitoring --------- . Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge [36rotmdwater Remediation
_ 19.SAND/GRAVEL PACK if a licable
Aquifer Storage-i ttd _ Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage f'
Experimental Techtto ogy Subsidence Control
Geothermat Closed Loop) Traeer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIMON color,hardness•soiLlrock type,grain sip Me
Geothermal(Heating/Cooling Return -r Other(explain under#21 Remarks)
4.Date Well(s)Completed: ' Well ID# GX
5a.Wen L'o}cat(igln�,( ft. � t
eft. �G ft t
Facility/Owner Name Facility ID#(if applicable) ft. ft. �' j
A
Physical Address,City,and ft. ft.
zL REMARKS infermagen
county,�fParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lar/long is sufficient) 22.Certifiea'
N W
6.Is(are)the well(s)Oermanent or OTemporary Sigoator of Certified Weu Contractor Datc
By signing this.form,I hereby certify that the twIlts)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
1f 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#21 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 cocstntction details. You may also attach additional pages if necessary.
drilled: o SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �5 (ft-) 24a. For Ml Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
i
10.Static water level below top of casing: �f�i2 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (> (in.) 24b.For Inlection 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
12.Well construction method: f�7V �y �"-7 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) �$ Method of test: ✓^ _ 24c.For Water Sunph&Infection Wells: In addition to sending the form to
�� the address(es) above, also submit one copy of this foot within 30 days of
13h.Disinfec�lon tune: /)L,/— Amount: 7.71_ completion of well construction to the county health department of the county