GW1--06755_Well Construction - GW1_20241112

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i ,
WELL' .CONSTRUCTION RECORD - '
Otis font ran bey scd for single or multililc;ells'...---.7"-- For totem it Use ONLY:
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1.Well Contractor Information: "
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-.-/
--•
• ^Mitchell Dean Cook 1A,IER%OES _ -: . . T_
______ . FROM To__^ ^_-D CROT70i.WrllConnactorNane
• -(20't f /7J IL:, . I 1 _ _ ._
• NC Well Contractor(rnificapmt Ntnobcr
15,OUTER(ASINC-(for moth cased•ivellsIOR,LINERSif Applicable _ _
•' • .Dennis Holland Well-Drilling, Inc ' l A
FROM L TO l DI AM THKNESS-', MATERIAL
ft Ir ft _ 1 .,• m
•
Company Name �--•-•
. •= . �. .
16;INNER CAS1N(—OR TUB�Yf'(g cotheraial:closed-too
• 2.Well ConsltUetion Pcr:trutfl; •-• ", • _ now '-TO DIAMETER7. IHIGKNESS MATERIAL -
16077•� B ift r .ft., ' in'
."(.isuttl'applicablewellpaOnits(i.e.County,.State,•Vnrirince,njectio�tc.)�- • _ -,�•Q " �"' ,�.�
3.Well Use(check well use): �� 'ft. --ft. i io. �ry" 75 i
WAter.Supply Well; �__ •�_ 17.SCRF:F:N -- - ',71"� _ vG- � •
•F.ROM �ro- ,niamtaF:R SLOT SIZE THICKNESS MA'1'F:RIAI.
°Agricultural ' • LJMtuticipal/Public rt. ft. in,:
•
f:ICieothennal(Heating/Cooling Supply) 7 sidcntial Wider Supply(single) ft. ^�R. • in', '! --
❑hulustriallCrnnmercial (_)Residential Water Supply(shared) 18.GRUUT_ ' " " -- - ----• -
111171 HIIOII_ t.RONI. -,-'10",_ MATERIAL EMPLACEM ENT MET)1OD hAMOUNT
Non Water Supply Well: ''------------7- aft. 3 ' ft, ,76�s ^',C2y ' ,[ !J
C1Monttoring IJRecovery. -ft F4- ft. r / "^�
Injection WeIL _ _ _�.� -ft. r fr, tJ
(]Aquifer Recharge [JOroundwaterR.eritediatii;i - •.19.SAND/GRAVEL.PACK`01epp1icab1e)..• '
•OAquifer Storage and Recovery CJS slaiity Barrier FROM TO NIATERIA1. . . EMFLACEMKNTMETHOD
DAquifer'lest ft. ft. ,'
OStormwater Drainage - — -_--� -
I]E:xperimmnlal'fcchunlogY • 0Subsidence Conttol ft. - ft.
_ i
UCieolhcfltial(Closed Loop) 20;DRILLING LOG attaeh additional sheets if aeeestml__ � __
p) L�Trabel' FROM TO.. DESCRIY1lON color,hardness,soWrock i
..�...._ _...._ zpr,brain slop aic.l_°Geothermal(Heating/Cooling Return) -00ther(explain tinder M2f Remarks) ft. • ft. l•
•
a, Date Well(s)Completed; c f p :2 1y a Lett_ f V ll r ft.
_rr,�_.- t` - - _ _ "
e _
ft. . ft, - • J
Sa.Well Location:
i / • T ft. ., ft.
1G nor y6Ql2 y, ���� Z — ft. _rt__ I , _ -_- _ „.._ ��._:'
.Facility/Owner Name Facility IDll(if applicable) ----• .- --•.-_.--•.._.-•--.-__....I .._..:_. . k
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.. :. l P 1.�" .,Liu/✓Q4( .._,.
- .._.r�._____.__:,t . _- . -_ _1 o—v-T—F LOZ4 _".-
Physical Address,City,and Zip __ • --- '_ �_._ __—
' 21.REMARKS ^ti
County ._-• —
•Pturcl identification No.(PIN) f • c•� '�
Sb.L,atitude and longitude is degrees/minutes/seconds or decimal degrees: ` � . I•
._-.,� _ __ ____
lit wall field,one lattleng is sufficient) 22,certification:
-Isp iV �_lS''__ .:,. ; G -2 ' 6'" 'W .-..dd t 't... ..&Ll__._ fael_:..L �./Z'—. / - -2'/
Signature, if Certified Well Contractor • Date
Lii.Is(are)the.well(s): I Ls;f'mancut or ClTernporary
fly signing this farm,/hereby certify that the well(s)was(were)constructed in accordance
with iSA NCAC 02C.010Q or,l5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing Well: IDYes or LriNS - - copy of this record has been provided to the well owner.
II this is a repair,fill out known well construction iiJorrnation and espluiri the nature of the
repair under 11 /renrarkrsedtionaronthehackofthisforte, 23.Site diagram or additional well'details:
1_
You may use,the back ol'this page,to provide additional well site details or well
R.Number of wells constructed:� _ •__"•
___ construction dctirils. You may also attach additional pages if necessary.
For multiple injection or Moll-water supply wells ONLY with the smile cotistruction•you cani
submit one form. SUBM1TTAL,INS i'UCTiONS '
•
(U (ft.) 24a, 1' f jJ Wells: Subtiiit this fuler within 30 days of completion of well
9.Total well depth below laud surface:•_
For Multiple wells list all depths ifdifferent(example-1«200'and 2C100') • construction to the followinit: ;. i
t
c2.J= _(ft.) Division of Water Resources,Information Processing Unit',10.static water level below top of casing:: .•
it+vnter level ir above casing,ise' - 161'7•I Lail Service('.enter,R'aleigh;NC:-27699-1617' '
11.•Borehole diameter: 6,+ in. I-,.jon Wells ONLY: lrl addition to sendingthe form to the address in
(• ' ) ,2dh. For In'act
Rotary ,24a above, also suhinit-a,copy•of,this)Ionn,within+:30 days:of c:o_mpletion-of,yell
12.Well construction method:__- ,. • - - coilstniction to the following:
(re.auger,rotary,cable,direct push,etc.) - i
_ - Division of Water Resources,UndergroundI Injection Control Program,
FOR�1'A'fBR SUPPLY Vs F1.,LS ONLY: T - 1636 Mail Service:.Cerktel' Raleigh,,NC 27699-1636
... ,
13a.Yield(gpm) .. _.,,3p fir lift 24c.For Water Su l Injection Wells:
- Method of test:__.....,.. - --_..,_...._ submit
one
I`{ Also submit one copy of this form .within 30 days of completion of
13b.C)isinfection type:.__..- Amount: . 2 02, well construction to the county health Idepartlnent of the county where
_...._.__....-.._..._. ._._... _....._......_.._. ..
— ,— w contitructcd.
Form OW-I - North Carolina Department Of lnVironnicnl and Natural kesourees•-Division of Water Resow'ees Revised August 2013
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