GW1-2022-06763_Well Construction - GW1_20220713

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID FOSTER COOK 14.WATER ZONES
FROM TO DESCRIi'TI
Well Contractor Name
4495-A (j rt. v ft. Ste,
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a ticable)
DAVID COOK'S PLUMBING FROMM TO DLIMETER T'IIIICTEESS DL1 E)RIAL
v ft. �'`ljft. in.
Company Name /
16.INNER CASING OR TUBING(geothermal closed-loa
2.Well Construction Permit#: FRONT TO DIAMETER THICKNESS MATERIAL
List all applicable tie//construction permits(i.e. UIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS DIATERIAL
Agricultural nicipal/Public Jft. l Jft. in. `(t �'
Res
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in. 3i
Industrial/Cominercial DResidential Water Supply(shared) 18.GROUT
Irrigation FRODT TO DIATERIAL EMPLACEMENT METHOD&ADIOUNT
Non-Water Supply Well: tt. ft-
Mon it.'irig— -- ---- DRceovcry- - - --- — fL-----ft — '.�---- — --- —
Injection We
Aquifer Recharge Sroundwater Remediation 19.SANDIGRAVEL PACK(if applicable)
Aquifer Storage'an ecovery �� ❑ISalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test Q Stotmwater Drainage 0 ft. L ft. LA
IA ��f
ExperinientaI urology Subsi ence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock is e.••rain size,etc.)
Geothermal(Heating/Cooling Return) —•Other(explain under#21 Remarks) tJ ft. ft. � J-3 vP
4.Date Well(s)Completed: Well ID# ft. v ft.
Sa.Well Location:
ft. ft
Facility/Owner Name Facility iD#(if applicable) „Cl ft. �7 Ll ft. S 7
. / .
562 �;rr!►yeX'RiAac C� ife�,db�i� c; NC 'L7��� 3 �R.
Physical Address,City,and Zip
1 ft
ft. ftft- n (_.. �4
1 o f t�� 21.REMARKS
vo 2
County Parcel Identification No.(PIN)
5b.Latitude and lon itudein degrees/minutes/seconds or decimal degrees: rj,�^r. °•.11' tiv t 1\
?.; e7 ti• I i
(ifwell field,one ladlong is sufficient) 22.Certificatio
N W
6.Is(are)the well(s)OPermanent or EITemporar v/ - Signature of Ccnified Well Contractor - — Date— `—
� By sighing this form,I hereby certify that the ivell(s)ryas(were)constructed in accordance
7.is this a repair to an existing well: QYes or 0/,No with 15A A'CAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards(Intl 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#21 remarks section or on the back of this•form.
23.Site diagram or additional well details:
3.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 1 GW-1 is needed. Indicate TOTAL NUNMER of wells construction details. You may also attach additional pages if necessary.
drilled: J SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 6 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(eraniple-3@200'andf22@100') construction to the following:
10.Static water level below top of casing: d (ft.) Division of Water Resources,Information Processing Unit,
If,rater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Ip. 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also qubmit one copy of this form within 30 days of completion of well
12.Wyll 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 WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection tune:0 /li.a.A Amount: completion of well construction to the county health department of the county