GW1--01946_Well Construction - GW1_20240325

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14;WATERZONES .
Mitchell Dean Cook FROM TO DESCRIPTION
Well Contractor Name /2G')o'ft. / 2/ ft. I '
2043 A ft. a ft. •
NC Well Contractor Certification Number 15rOUTER' ASING(foemulti-cesed'wells)`OR•LINER•(if:ap licable) : -" .
FROM TO DIAMETER THICKNESS MATERIAL
Dennis Holland Well Drilling, Inc. ft. ' ft. in.
Company Name 16:INNER CASING;OR-TUBING(1 eothermaLclosed=loop). . -
FROM• TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:.2© 2-4-9"y"a g Y8 ft, ft J i in.t, >•�2410 9g 512KA,2/ /c —/A .,•
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) Vc.G��fG�� it. A=,r to } '
3.Well Use(check well use): ' . ' r g 'd'i
•
17.SCREEN•. " •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL_
ft. ft. in.
❑Agricultural DMunicipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.:
❑Industrial/Commercial ❑Residential Water Supply(shared) ,18.GROUT ,: . . .,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation Non-Water Supply Well: ft• -� r f Jf2,e .s rJ
C,� �irril 7
• ❑Monitoring ❑Recovery 3 ' ft. -?,c), ft. i)45.s1i /. 1,t 04 71i /,e-.1
Injection Well: ft. ft. {
❑Aquifer Recharge ❑Groundwater Remediation •-19.SAND/GRAVEL PACK(if applicable]..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
ft. ft.
DAquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
,20.DRILLING'LO.G:(agaeh'additionabh tots if.necessary)
❑Geothermal(Closed Loop) ❑Tracer. FROM I TO DESCRIPTION(color,hardness,soil/rock t roc rain size,etc.)
• ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
• ft. ft. 1
ft. ft. .
4.Date Well(s)Completed:o3••13...2 f Well MN AZ /A . 7-----
ft. ft. 'C M;t -,.-.
5a.Well Location: r 't.. e l
• ft. ft. t.' ,
I r cse? 8.0 c.: /cam,e...G/I- .vim hi-.. ft. ft. r t` Z024
Facility/Owner Name Facility ID11(if applicable) — ft. ft -- — ----
l/F7 Lafdvyr IyCc/ .Qe,1/� it'd , f� ft. . effeiaJ
Physical Address,City,and Zip 21.REMARKS
✓'c,c: ,;rrj 753 e, --.36--_6-1414e ?P '0 i
County Parcel.Identification No.(PIN) , ��~ �+ / (le
i� -" �=�/.
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) - „
35 1 r� N '<s�� ) w ?, . .4 '-/ _ ems
� Signahtreof Certified Well.Contractor ' Date
6.Is(are)the well(s): lM° rmanent or CDTcmporary
By signing this form,I hereby cert0 that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and than a
7.Is this a repair to an existing well: DYes or 11No _ - _ 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 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple infection or non-water.supply wells ONLY with the same construction,you can
submit ore form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 ei.3 = (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:- (-) (ft.)
ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.)
24b.For Injection Wells ONLY: In addition to sendingthe form to the address in
Rota 24a above, also submit a copy of,this form within 30 days of completion of well
12.Well construction method: ry construction to the following: ,
Ir ,
(i.c.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) Air lift 24c.For Water Supply&Injection Wells:
/ 0 Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: H &H_____ Amount:.12 OZ. _-_ well construction to the county health department of the county where
constructed.
I .
Form OW-I North Carolina Department of Environment and Natural Resources--Division of Water Resources Revised August 2013
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