GW1--05788_Well Construction - GW1_20230901

•
.WELL,CONSTRUCTION RECORD ORI) -._ _- ;
ibis form can be,used for single or multiple.wells For lateral Use ONLY: ^^- _ _
1.Well Contractor Information;
Mitchell Dean Cook -- _-__.___-__ t _ _._...-.__ _-,_..__
Well Contractor p'ROM - I•:L_. t _ >a'r '•!'
Rtt Nnmc ..._T�- `DF.SCRiY770N
20�3 A �2.Lc-1t._ 1�%`"°rt. -C ! — ---------
NC Well Contractor Certification Number ft. fe�-' --_--- -
'L S QIJTI;111 tiV, . f6Yidiull r 1Tr Thi. n•: .-..
.i .f�.,.. ( t�:i•�'s`�t1:,wetle;�'k) :NINE: .?irp' )7i'cA c .,
Dennis Holland Well Drilling :01 TO ATERI''" "-
Inc.In(: ft. ��AMF' IICK MATE...._...._...__ DI ,7 FRI 't7 NESS TERIAL
Company Name -_ _ f �.� i yin
1:6 if!tNF)tl.'CiASIN!rc()lt'TIIRttlftO. lierma <,, t;n
-
L_ �P,e.'o'j y>"closrit=loop}_Zt,` r:z;f�t ;' "'
2,Well Construction Permit II: I ,FROAt TO DIAMF.Til J�' -'-----•-
1st all applicable well pumas(i.e.(Darr..2,../
i `1 -•- _- ' rt. ft. ln. Tit �_-�-L ._._--.-
ry,Stare. Vnrrnnce:Injection,;70) _
MATl;RIA
3.Well Ilse(check w dt• rr. =✓ o ; -
(• k well use). q'
1T,f,`
atel.supply
Well: _______••-___...___________._-_-_......-_-_ ___..i.____. 4_,_•� .................................to :;; s ,....1.
C:IAgricultbral t. Ir.
D IAht FTF_R .SLOT§:ME• THICKNESS...,:MATERIAL_.
ft. fr. in.1
I:.]Munici)>aVPublic ,
0,cothernal(Heating,/Cooling Supply) C1Residential Water Supply(single) ft• ft. in,I ,
Oln(lustritl/Commeroial
_._._____....
ClResidential'Water Supplyar8,4---,-.1 m ;ia: ''''' <y.;:;" --•- .-._.
(shared) :J•
• Curti union _ •F7ioni '�{' :;;a,., °`' S' :i'
Ix ._._- _.__..o__..__+ -ALITERI6I. _ him PLACEntENTM.F.THOQ&AMOtinI
Non-Water S(tpplyWell: --_..._._.._-_.._.-.._._.._.__-.---T..___ ,ft. ..ft. -
_C:1Monitoring filkeeovety
Injection Well: _ _.�_.. _ _ __._ _ _ -., __._,-._.... _..._-- e.dz27.2 - �.�(x •S'_ .. d
(.7Aquifer Recharge ft. ft.
ClCirouudwaler Rentediati _ t -
• on E.0...a.tiD%GriViik?PRe/ Irti'giii r ---.-x-
DAquifer Storage and Recovery (.JSaltilily I)arfief FROM -- r�)_._�_ ,_MATERIAI. E:MPLACEM ENT MEni0D -
fJAquifer'fest ft. ft. 1_
CI Stornlwater Drainage . __-_
fJFxperimental Technologyf -t. ft.
�__• ___._. _____..
C]Subsidence Control
CJCiuJthennal (:Ins :2•7700 DRIL-----.-7-",-,---,f f 1 C)( a f8 ,ono' .•.,."�" •,r"'- -
((Closed Loop) (,:Phrne a Foi.:DR tft -( tfrighiG'Fd)trogal ihect'itCufee fiery) ,<;, a ?,;; ":< `^
f3Geothermal Hearin CoolinrReturn J:10ther(explaintinderinI Remarks) _ uFURIPTu)N(gotorthanlnssssoiVrucklypr�gr�;n.�i� ei�:__
ft. ft. l:
4.i)ate Well(s)Completed:O?:Z,�';-,Z�'tyell IPH - '
Sa.Well Location: _-.._. _ i 1/ d..�t_1_._d_.-_-_._--_
_ fr.ft. - ft.
7.2 he,�d za a , at _.___-_______-_-__.._____.._..__--__..__.-__ Z0
._
11.
Facility/Ownener Name . Facility ID/1(ifupplic blc) �_...;._.._...._...-_ _..___._.__._._.._._i__...-__._.,.__..__.-_... __...__....__..-v._.
..._.-.__._
at J Z h. yi.2� 0 U ft.
.._._.._.__... <<._. _..._._.__.
r-
•y� �rti �n rr
Physical Address City � - .' _ _nnd'Lit T.. __
521:#KB'11IiCIiK ':� T.' _ -
tt J 1
Colony Parcel Identification No.(PEN) C' .! *� _A______-_..._.__
Sb.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22 i
(if well field,one rat/long is sufficient) .(:crfiPCalion: i
S .2 l
' ._. � :_- „_--_-____ ___ - �
Sigaatue ofCertifed Well Contractor Date
6.Is(are)the well(s): 43.14manent or CJ1'cmporary
By signing this form,1 hereby certify that the well(s) was(were)constructed in accordance
with/.SA NCAC 02C.0100 or LSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to tin existing well: 0Yes or 641Altr- copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under(!21 remarks.section or on the hack ofthirform.
23.Site diagram or additioual well details:
You may use the back of this page tci`provide additional well site details or well
8.Number of wells constructed:
1 __ constuction details. You may also attach additional pages if necessary.
For rnnitiple to jecrion or nun-water.supply wells ONLY with the same construction.you can I
suborn One farm. S1111M1'r•1'Al.INS•fl1C:'1'fONS l
9.Total well depth below land Miriam: ,__ y ft, 24n. [or,_All \Yells: Submit this tii.'rni within :10 days of completion of well
For multiple wails list all depths if different(example-345200'and 2@100')' construction to the following: f
10.Static water level below top of casing: _-_, 4. ® - _ _- (f. Division of Water Resoui1ces,Information Processing Unit,
If water level is above casing,use"•1." -- "- 1617 Mail Service.Center,Raleigh,N( 27699-1617
eu" f '
11,Borehole diameter: __• -_-__ (ill,) 24b: For Injection Wells ONLY: hit addition to sending the form to the address in
Rotary 24a above, also submit is copy of this'form within 30 dhyS of completion of well
12.Well construction method: - construction to the following:
(i.c.auger,rotary;cable,direct pilsb,cic.) �'____ __.._�_
_
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
`—_- __._______.__ 1636 Mail Service Center;Raleigh,NC 27699-1636
13n.1'ield(glint)_.._..//_ �•-• Air lift•
24c.For WaterSuppj&Injection Wells:
(gI ) <J._,.__----. Method of test:---._.._..,_.. -
Also submit one copy of this form wtt tin•30 clays of completion of •
H & H •13b.Disinfection type:_-_ -_____.__. Amount:-�2 Uzi,•_-__.__. ____ well constructed.u lion.to the county health department of the county where
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