HomeMy WebLinkAboutGW1--06448_Well Construction - GW1_20241101 '.
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WELL CONSTRUCTION RECORD(GW-1) ... .,... .
For Internal Use only:
1.Well Contractor Infornution:
DAVID F. COOK 14.WATER ZONES ' i -.. ' ,.
W
FROM TO OESCRIPTIAN .eil Contractor Name.
ft.
4495-A- , ft. ft.
I '
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-ased.wetts),OR LLNER(if ar; ficidite)
DAVID COOKS PLUMBING FROM I To DIAMETER' THICKNESS' MATERIAL
'Co ny Name 0 ft, 39 ft. 1 ,iii r .1.• sci.its
.
Mpa
16.INNER CASING OR TUBING(neOthermal closed-loop), ., er".- . . '2.Well Construction Permit If:
FROM TO. . I DIAMETER THICKNESS MATERIAL Ust oft applicable well construction permits(1,e.PIG County,Suva,Varitmca,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft
Water Supply Well:
FROM TO DIAMETER i' SLOT SIZE THICKNESS MATERIAL
*Agricultural rjApinicipal/Publ!c tic,ft. ei ft. in. ,.,2
...‹,4
*Geothermal(Heating/Cooling Supply) 2absidential Water Supply(single) it. ft.
'II Industrial/Commercial ['Residential Water Supply(shared) ie.GROUT , ..- - .„ . ,- _
Irrigation FROM I TO . MATERIAL EMPLACEMENT METHOD&AMOUNT
.
Non-Water Supply-Weil. ' ei It. 0. U. t.:,e,,,.45 /9, 0,,-.
X Monitoring----- ---- ------ --- - iJR-F5Ci-ivei.:' '- —--- .- - ft. - ft. .1
Injection Well:
ft. A.
*Aquifer Recital ge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if ..applicable) ' • - - -." " "
*Aquifer Storage and Recovery - Oily Barrier - FROM ' TO I.MATERIAL E.MPLA CEMENT METHOD '
•$Aquifer Test EjStoniTivater Drainage .7, it. iv ft.
It Experimental Techrinlo,. [3Subsidence Control ft. ft.
a i Geothermal(Close. top) [JTracer ,20:-ORILLtNG LOG'attach additional sheets if necessary) .• - %..
FROM TO DESCRIPTION(color.hardness,soil/rack typt,grain size,etc)
Geothermal(Heating/Cooling Return) 1710ther(explain under 421 Remarks)
0 ft. r, . ft. -. .... I.A/
i
4,Date Well(s)Completed: tO (160 Weil LD# I I. „.4.--- 4„,1 ""F' f t. I
___.
Sa.Well!ocatlon I /6 1` ' 2
0 ‘f 6/ ft. . ,, ft. 04. ,I • •'-'" --..-.- .r.ii : ,) .1 :
&ditty/owner Name • - . ., 7,Facility I Dti(if applicable) /' -*. f`' ;--: NOV t? ' 2024
6'1 - -2-)4. ifikbH1 (11.1-L--. V\.IPVAIllail ' ft.
ft. ft.
ft. 1.
-, , -11-,fc:-;-:-,:!:.-.-: .-'•--, -., ‘-- - ,, •Pkitica1 Atkiress,Cl, and 74
LI . 12 tc','L..:;
‘..c..,..
21.REIVIARRS ...„,
11\)111'61r\i VII" 0 VA
County Parcel identification No.(PIN) 1. . ,
St).Latitude and longitude in degreeshninute_siseconds or decimal degrees: •
(if wail field.one let/long is sal ficient) 22.Certification. 1` -. .
4'1
. NV
. N . A:;751
s,gnarum 1st-vilified Weil Contractor- _ Date- --..- - -
.6.,1s(are)the:tvell(s)ematient.---or'__EITemporary---- --
By signing this form,thereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ['Yes or Be' with ISA NCAC(.12C.OWI)or I5A NCAC 02C.0200 Well Construction Standards and that o
If this is 4 repair,fill our known welt construction Information and e.xpialn the nature of the (14*of this record hot been Provided to the well owner-
repair under 421 remarks section or on the both of this farm
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Weils having the same You may use the back of this page to provide additiOnal well site details or well
cons-Unction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You mayalso quich additional pages if necessary_
drilled:
suumirrAL,INSTRUCTIONS
9.Total well depth below land surface: 57-1 (ft.) 24a. For All Wells: Submit this lonn within 30 days of completion of well
For inuftiple waifs lig all depths if different(example-.31a1200*gad 41,1100) Construction to the following:
10.Static-water level below top of casing: k (ft.) Division of Water Resottrcth,Information Processing Unit,
if water fewl is altow casing,we","
1617 Mall Service Center,Raleigh,NC 27699-1617
I:
11.Borehole diameter: eg (in.) 241.1.For Injection Wefig; In addition to sending the form to the address in 243
above,also submit one copy of thig,forth within 30 days of completion of well
12.Well construction method: ..PLW(9.7‘t construction to the following: i
(t e.auger...rotary,cable,direct push,Fle-1
' Division of Water Resources,Underground Injection Control Program,
ONLY:
FOR WATER SUPPLY WELLS 1 , -
1636 mail Service Center,Raleigh,NC 27699-1636
- I '
13a.Yield(gpm) .5"-- Method of test: 1/,‘...,,, 24c.For Water Supply&.Infection Wells: In addition to sending the form to
-the address(as) above, also submitone copy of this form within 30 days of
13b.Disinfection type: e..... ()qr.:. Amount: €;:x 4:Z.— completion of troll construction to:the,Ourity-health dtmartment of the county
where constructed.
Form GW.l North CZTOlitla Department of Etwironnwmal Quality•Division of'Water Resources !, Revised 2-22-21R6
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