GW1-2021-00824_Well Construction - GW1_20210215

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WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: Print Form
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contsamor Namc FHOaI TO UEBCRIPIION
2187-A
NC Well Connaetor Ceni Ovation Number
ft.
15.OUTER CASING formula-cased wells OR LINER(If Ruble
Hedden Brothers Well Drilling, Inc FROM TO DIAh1ETEH THICKNESS MATERIAL
Company Name
t. R. to.
16.INNER CASING OR TUEING(geothermal baedq.0
2.Well Construction Permit#; FRONI TO DIAMETER THICKNESS MATERIAL
Lw-11 pprrahrrurlIran..rtrnrnanpernmsr.e. ure,eannty.slate, Pananreetr.) Q ft.. fit m' �-re BL
3.Well Use(check well use): R. It. in.
Water Supply WeB: 17.SCREEN
FROM TO DIAMETER SLOTSI%E THICKNESS .MATERIAL
Agricultural Munici al/Public
P ft, ft. to.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single)
IndusltiaUCommercial Residential Water Supply(shared) R R Is
18.GROUT
)n- olio. FRU11 TO )IATERIAL E?IPL.ACE.\tEST.\IETHODS AMOUNT
Nan-Water Supply Well: D ft. 11a ft. pumped
Monitoring Recovery R ft
Inject...Well:
A uifcr Rcchar c ft• fL
q g aGroundwatcr Rcmcdiation
Aquifer Storage and Recovery,
19.SAND/GRAVEL PACK ifs ❑cable
6 a$ahnity Barrier FROM TO MATERIAL E)1PLACEMENT)IETHOD
Aquifer Test aStomiwater Drainage ft. ft.
Experimental Technology Q'Subsidence Control R• fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach.... .d sheets a.ecesse
Geahermal(Heat:. Cooling Rerum) -Other(ex lain under#21 Remarks) vaoal ro oF'scatrnoN imm<,6amne,,.soiu,a<e
b.
��1,21121
"� �' (� 0 ft. day a sane
4.Date Wells)Completed:�p�( Well ID' I DA 0. I p. 9male
Sa.Well Location: I 1 ft. n.
i e„ MaC.0 .l._,1 ft. I rL
Fac 1aDyy/O . mc Na -T Facility 11)(ifapplicablcl ft. ft
//n .
L.� eel M- Jq ICSOn� .98717 ft. n.
Physical Address,Cnt .and Lie T ft. ft.
JACV`^'J Ctwwr� -758a2-a110-89315 2,.RE.fARKS
Couney Parcel IJcmiimmion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwdl field,one IaVlong is su Hlcicnp 22.Certification:
35° 1)7, '797 N of W
ry) a aoa
6.IS(are)the well(s)>i ryPermanent or Temporary SigwlureofCmificd Wdl C, ad".' Darc
T 91 siyn;ng Jns/orm,I h,,b, c"" rhnc r nPllfrl �rar pro e)ronslrunrd in accordanre
7.Is this a repair to an existing well: ayes or No ailb 64 NCAC 02C.0100 or I5,4 NCAC 02C.0200 HIM Constrevien Standards and that a
/J'/hu isarrpaicJ:ll out knmvnvrl/cmmrta'lion ilfarrnalian AMWein the nann'e o/th` ropy oflhis rrcord has been p�n,,d,d to lhcu, it uner.
repair under 921 renmrla section w on the bavA'ofthisjoruz q \
r� lO b' '-3.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells hay�,Wggke ame You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUM 6ER ofweils construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 1000 (ft-) 24a. For All Wells: Submit this fo m within 30 days of completion of well
Fa nndt;plr nett.,hrt aft depths d diRn'em ternluple-3rg 200'and 2gJ00'1
construction to the f.ilowtne
w :
10.Static water level belo top of casing: OM (ft.) Division of Water Resources,Information Processing Unit,
//tracer/etw/s nbmr rasing,usr- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: $2 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_al 11 cmistmction to the following:
o e.auger,mtuty cable,direct push,etc.)
D Asion of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Method of test-. 24c. For Rater Supply S In'ect'o Wells: In addition to sendine the fo= to
the addiess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:
H Amount; he
of well construction to the county health department of the count%
whey-conetnmtcJ.
Fonn G\t'-I North Carolina Department of En, ronn:en:-1 Qmlin'-Dicislor.of Water R;Seur ec