GW1-2022-09498_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID COOK 14.WATER ZONES
FROM TO DFS RIFT[
Well Contractor Name I .
4495-A -
NC Well Contractor Certification Number 15.OUTER CASING(for multi=cased wells OR LINER if applicable)
DAVID COOKS PLUMBING FROM TO DMIETER THICKNESS MATERIAL
in. J y0 �tv
Company Name
16.INNER CASING OR:TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS - MATERIAL
List all applicable well consiniction permits(i.e. UIC,Count}t State, Variance,etc.) ft• ft• �!t'
3.Well Use(check well use): ft. ft. it
17.SCREE
i -
Water Supply Well: FROaI TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic U ft. tt. in. I �G 7� uc.
Geothermal(Heating/Cooling Supply) xDResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT, . ...
--th-riization FROM TO MATERUL EMPLACEMENTMETHODR AMOUNT
Non-Water Supply Well: © ft. ft.
Monitoring Recovery
Injection Well:
Aquifer RechargeGroundwater Remediation
1%SAND/GRAVEL PACK(if a licaltle,
Aquifer Storage and Recovery ❑ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorrmvater DrainageZ6 ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) ©ITracer 20:DRILLING LOG'attach-additional sheets if necessary)
FROM TO DESCRIPTION(color. ardness,soillrock type,grain size,etc
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) � ft. ' • ft. � S•
9/28/22
4.Date Well(s).Comp)eted: Wel1ID#
5a.Well Location: -_
SALVADOR AGUIL'ERA �
Facili lONnerNamc - ` ft-
Facility ID# ifa licable J ft
ry ty (� PP ) -
1200 HOLLY LANE JAMESVILLE, NC 27846 e. ft.,
Physical Address,City,and Zip ft. ft. ._n ril
MARTIN :21;,REMARKS
County Parcel Identification No.(PIN) V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W (( 1194-0y
%
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified Well Con for Date '
By signing this fornt,1 hereby certifi,that the rve/l(v)was(were)constructed in accordance
7.Is this a repair to an existing well• [Dyes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 rentai•6s section or on the back of this forth
23.Site diagram or additional well details:
S.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: �,l (ft-) 24a. For All)Wells: Submit this form within 37 days of completion of well
For multiple wells list all depths ifdiiferent(trample-3@200'and 1@100') consttltctiott to the following:
ill.Static water level below top of casing: J 7 - (ft.) Division of Water Resources,Information Processing Unit,
ljxater lerel is aboyecasing,rise,"+/ 1617 Mail Service Center,Raleigh,NC 276994617
11:Borehole diameter: (C1 (in.)` 24b.For Infection Wells: In addition!to sending the form to the address in 24a
,9 � above,-also submit one copy of this form within 30 days of completion of.well
12.Well construction method: /4 14✓ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYrWELLS ONLY: A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(,-pm) J> Method of test: a `z 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
12h Ilicinfnrtinn t.,n,.• /'Gt6 . rl r -An,..,rm- 7�'L completion of well construction to the county health department of the county
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