GW1-2023-01075_Well Construction - GW1_20230125

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information: i
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DAVID COOK 1 14.WATER ZONES !
FROM TO I DESCRIPTION
Well Contractor Name ft. S
4495-A G 0 ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells'OR LINER if a licable
DAVID COOKS PLUMBING FRO31 TO DLAMETER I THICKNESS MATERIAL
t. I ft. in. SG 17G�J UL
Company Name
16.INNER CASING OR TLhBING cothermal closed-Ioo
2.Well Construction Permit#• FROM TO DIAMETER ' THICKNESS MATERIAL
List all applic•ahle welt consruction permits 0.e.UIC,Counts.State, I'arirrnce,etc..) ft. ft. in.
3.Well Use(check well use):
17.SCREEN i
Water Supply Well: FROM TO DIAMETER SLOT SIZE TH[C MESS \i.4TERI.4L
Agricultural [] umcipal/Public Jft. �t�t. in. t) SG �J GC-
Geothermal(Heating/Cooling Supply) fRcsidential Water Supply(single) fr. ft. in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irrieation FRO3i I TO 11ATERI L EMPLACEMENT METHOD&.01OUNT
Non-Water Supply Well: fi. fi. O�-
Monitoring []Recovery --
Injection Well: fr. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MAT ERiAT. F.1iPLACENiENT 31ETHOD
Aquifer Test []Stornnvater Drainage /ft. /�v ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM DESCRIPTION(col ,hardness,soiVrnck h rain site,etc.)
Geothermal(Heating/Cooling Return) Other(explain under;#21 Remarks) ft. ft.
p�
4.Date Well(s)Completed: U Well ID# tt' fr•
5a.Well Location:
�G.1LldlL v ft• ' C) ft. s I � a �.
Facility/OwnJ Name Facility ID#(ifapplliicca�blle) J /, ft. ` ft. G
I` a110
11� V ft. !'f ft. d� i;/ a� nti•r?i53ilD•� �fr� >y? )
Physical Address,City and'ip
21.REM
County �l` 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification: {'
N W DIOA I.
-. - 6.Is(are)the well(s)ox Permanent_ or,D-fgmporary Signature pf Cenificd Well Contractor !' DWI
By.signing this firm.1 herehr certili'that the sIvI1Ls1 was(were)c•onstrrurted in accordance
7.Is this a repair to an existing well: []Yes or E)No ivitb 13A NCAC 02C.010d or 15A VCAC 02C.0200 well Construction Standards and that a
if this is a repair,fill out known well consintrtion inlarniation and explain the nature of the. cops'ql this record hms been provided to the well owner.
repair under#21 remarks section a-on the back of fW form-
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL LNSTRUCTIONS
9.Total well depth below land surface:�//,,-C) (ft•) 24a. For All Wells: Submit this ,lform within 30 days Vof completion of well
For multiple ivells list all depths lt'dlfferear(eraniple-3;20{0''and 1 d 100') construyjtorrfo the following:
10.Static water level below top of casing: ')O (ft.) Division of Water Resources,Information Processing Unit,
1/„aver level is above rasing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: (in.} 24b.For Iniectfon 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: construction to the following:
(i.e.auger,rotary,cable,`direct push.etc.)
Division of Water Resources,Uit derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361 Service Cent i r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Sunnily&Inlecti I Wells: In addition to sending the form to
/ the address(es) above, also submitl one copy of this form within 30 days of
lZh Dicinfortinn tcnp: �41, Arnmrnt: t)?_ completion of well construction to the county health department of the county