GW1--00464_Well Construction - GW1_20240116

WELL CONSTRUCTION'RECORDi ,
For mtema]Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: i ..
Mitchell Dean Cook 14.WATER ZONES.•. I ' ' ' '-
FROM TO DESCRIPTION
Well Contractor Name /�')©'ft ,•�/a ft
2043 A fs� ft. •ar ft.
NC Well Contractor Certification Number `1S::OUTER'CA'SING,(for:multi,cnsed;wells)',OR LINER•(ifappliciible)'.-" ; , -
—
FROM TO DIAMETER I - THICKNESS MATERIAL
d
Dennis Holland Well Drilling, Inc. l ft. 7t- ' ft. i�„I ,it. 544,..2THICKNESS
, P Ee;
• Company Name 16::INNER'CASING<OR:T_UBINGeothermalclosed-loop);_. -.
FROM TO DIAMETER , THICKNESS MATERIAL
2.Well Construction Permit#: t> a.,.1.3 -p ft. ft. I in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 11 SCREEN "1 1 .
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL..
❑Agricultural ❑MunicipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in. f
❑hidustrial/Commercial residential Water Supply(shared) I8:GROUT ::'
. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: e • ft. - 7•_it,- Far/•/a los/ :-_bei -P4mCpC'c�
❑Monitoring °Recovery IL .,2,0 ' ft- jJj,' jy#rib 6 2-, v e /'is,g,,.�ri
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation , 19.SAND/GRAVEI;PACK(ifapplicable)'.. . . •- .
FROM TO MATERIAL ' EMPLACEMENTMETBOI)
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. 1
•
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
.20:DRILLING LOG'(attaeli additional`sbects ifneceasary).
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Rerun) ❑Other(explain under#21 Remarks) ft. ft. , j ,
ft. ft.
I ,
4.Date Well(s)Completed:4!--O9;,.A Well ID#i ''23 - 5 ft. ft.
5a.Well Location: ft. ft. •
/14/A. ft. ft. • 4 p ,
Facility/C wncr Name Facility ID#(if applicable) ___- ft. — _-- ft. . Fi ..;,..b _
,3 95 s'ht'r i/f/ejcl R.S ft. ft. JAN 1 202n
Physical Address,City,and Zip 2L-REMARKS. . ' - . ,
T_/✓tdc'v7 G5q.R3_s'1c .. . inform-aim fir„��:� U • ,
County Parcel Identification No.(PIN) ;`_. •
•
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one tat/long is sufficient) }
5 n 7:;2. , 45� N 636'3 /3,76%2- W 'j � —,_—_—_- d/4 -.,2e? 4z
Signature of Certified Well Contractor , Date
6.-Is(arc)the-Well(s): 'permanent- or GTemporary_ _ •- - By signing-this form,.1 hereby certifythat the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or taNi 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 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the hack.of this page to provide additional well site details or well
S.Numberof wells constructed: ' construction details. You may also rittach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can i
submit one form. SUBMITTAL INSTUCTIONS I
9.Total well depth below land surface: 7 Sri ' (ft.) 24a. For All Wells: Submit this;forrn within 30 days of completion of well
For multiple wells list all depths ifd different(example-3@200'and 2@l00) construction to the following:
1 '
10.Static water level below top of casing: 30' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C n ter,Raleigh,NC 27699-1617
6" 24b.For Injection Wells ONLY: {Inaddition to sending the form to the address in
11.Borehole diameter: (in.)
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction.method:- Rotary-
method:- to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Air lift 24c.For Water Supply&Injection Wells:
13a.Yield(gpm)-_ Method of test: -- Also submit one copy of this form within 30 days of completion of
,(a •_ well construction to the county health department of the county where
13b.Disinfection type: H & __^.___ Amount:, 2. ______-
constructed. i
1Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water R
sources Revised August 2013