GW1-2021-06920_Well Construction - GW1_20210505

Print Fo"'rm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1-Well Contractor information:
Russell Taylor 14.IN'ATERZONES
Well Contractor Name FROM TO I DESCRIPTION
2187-A i L+0 ft. sj 5 fi.
Ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull cased wells OR LINER(if a licable
Redden Brothers Well Drilling, Inc FROM rcl D1AatETER rHicIGNEss MATERIAL
fr,Company Name 11. In.
q 16,INNER CASING OR TtiBING eothermal closed-lootsl
2.Well Construction Permit#: p'�Oo?b ��?- Q- a g FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UiC,County,State,Variance,etc.) 0 ft.-
43 fL -to t in. nV(
3•Well Use(check well use): y ft. 45 ft. in. 122 rgE L
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
Agricultural SMunicipal/Public ft. ft. in.
_'Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18,GROL*f
_ Irrigation FROM TO I MATERIAL I EtIPLACE1fE.NT tIETHOD S A.\IOtiNT
Non-Water Supply Weil: 0 rt. 20 R. r�vcaawu. pumped
Monitoring Recovery ft. ft.
Injection Welt:
ft. ft.
Aquifer Recharge E)Groundwatcr Rcmediation
19.SAND/GRAVEL PACK if a licable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EM LACEAf T METHOD
Aquifer Test Ostotmwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To I DESCRIPTION rcolor,hardness,soil/rock rype rain size.etc.)
ft. C9tt. clay 3 sand
4.Date Well(s)Completed: Well ID# 36 fr. I t ft. I granite
Sa.Well Location: ft.
ft. ft.
e,r,a rac#cL t
Facility/Owner Name Facility IDa(if applicable)
0733 B �.
{,Ch r ay` ►�I x� y�(yc� a 8`Ie79 ft. ft. no
Physical Address,Cr�'1 CA
d Zip �+^ ,a
sa CAUNnj 25a$>04—,3 21.REMARKS
County ^—�— Parcel Identification No.(PI.N)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwctl field,one ha/long is sufficient) 22.Certification:
350 Ite,t7r7 t N 0236 1'7.3t08 w � ai
6.Is(are)the well(s)apermartent or 017remporary Signature of Certified Wcil Contractor Date
By signing this Jams,I herebv certify that s 1171101 was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or No with 15A NCAC 02C,0100 or 1SA NCAC 02C.0200 Well Consn7ection Standards and that a
ljN�is is a repair,fill out kaow�t tveB carstntction it jorrnationPle.yplain the nature of the copy ojthic record has been provided to the well owner,
repair under#21 renzarkssection or on the back ofthis jonn. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple trells list all depths i(dij)erent ierample-3@200'and 2@100') construction to the follow•tne:
10.Static water level below top of casing: too (ft.) Division of beater Resources,Information Processing Unit,
Iftvater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _ (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one cop} of this form Within 30 days of completion of well
12.Well construction method: IQ�jt , construction to the foliawing:
(i.e,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.YleId(gpm) fJTa Method of test: &Ml^^
24c.For Water Suooh•&Injection Wells: In addition to sending the form to
{� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �r,_ Amount: completion of well construction to the county health department of the county
n>here constructed.
Form GAL'-i North Carolina Department of Emironmcnial Quality-Division,o,Waster Resources Revised'__2_016