GW1-2022-00203_Well Construction - GW1_20221216

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID COOK 14.:WATERZONES.
FROM TO DESCRIPTI '
Well Contractor Name
ft.
4495-A
ft. �Uft. rj4✓I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells R O LINER if a licable
DAVID COOKS PLUMBING FROM TO DIAMETER THICKNESS MATERIAL
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: fd FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. ft. in.
17.SCREEN
Water Supply Well: FROM I TO I DIAMETER ISLOTSIZE I THICKNESS I MATERIAL
Agricultural Municipal/Public .9,21tt. ;2410 ft. in• �po sC L � vL
Geothermal(Heating/Cooling Supply) rResidential Water Supply(single) ft. I ft.
RIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
Inigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. - it.
Monitoring ORccovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licatilc):
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT MFTIIOD
Aquifer Test [3Stor-mwater Drainage v o ft. rya ft. ^ ✓a D V
Experimental Technology [I Subsidence Control
Geothermal(Closed Loop) DTracer -20.DRILLING LOG'(attach'additioital:sheets if necessary):
FROM TO DESCRIPTION(color,hardness•soillrock e, rain size,ctc
BGeothennal.(Heating/Cooling Return) Other(explain-under#21 Remarks)
4.Date.Well(s)Completed:. N
Well ID# it. ,tr. /115.
Sa.Well Location: ft:. /
'; ft. JJ ft.. ! Jell..
Facility/OwncrName,, 0 Fa iD#(ifapplicablc) ft' t� ft'
3�' aid 1`r 1w 0/1 F 0 r/3( u6b \`c/ 6/ft. /9 ft.
Physical Address,City,and Zip ft. 7 ft.
/1 L,V 21.REMARKS- / _ `� i
'JI � .
County Parcel Identification No.(PIN)
I,D`tui Fri
?s-wi�1 ?'�i %%:it:,l.`.y •r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifieatio - —'
6.Is(are)the w•ell(s)oPermanent or [3Temporary SignaturcrofOdfiffied Well Contractor Date
By signing this forn,I hereby certify that the well(s)it-as(were)cautntcted in accordurrce
7.Is this a repair to an existing well: DYes or )No with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Nell Construction Standards and that a
1f this is a repair,full out known well construction in fornualion and explain the nature of the copy of this record has been provided to die well owner.
repair-yonder#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-1 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: k W f0 24a. For'Ali Wells: Submit this form within_30'days of completion of well
Ibrrnaltiple wells list all depths if di.Jfeeent(eraniple-3@200;and 2@100') - construction to the toll owing:
10:Static water level below top ofcasing•. —1 D (ft.) Division of Water Resources,Information Processing Unit,
If hater level is above casing,use"+" 1617-Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)' 24b.For Infection Wells: In addition to sending the form to the address in 24a
1//�•L/i 1/'� above, also submit one copy of this,form within 30 days of completion of well
12.Well construction method: 1 Y li'1(/l�l 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: vM 24c.For Water Supply&Iniection Wells: In addition to sending the form to wo
— --the-address(es)-above;also-submitlone-copy-of-this-form-within-30-days-of
13h.Disinfection tvne: Amount: _ completion of well construction to the county health department of the county