GW1-2021-06923_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: fr
Russell Taylor R;:CEi_- 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A X 'a' 2021 J1.2 130 ft 401 - *14
NC Well Contractor Certification Number LC eft. 1
15.OUTER CASING for multi-cased
R LINER(if up2licable)
Hedden Brothers Well Drilling, Inc Secton FROM-1 zpffl ro THICKNESS I MATERIAL
In.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 0:01090 -1900" 19-C105 1 FROM TO DIAMETER THIC"ESS MATERIAL
"A'
List all appitrable well construction pertnits ri.c.UIC,Country,State,Plarimire,etc) ft. 40 It. In
3.Well Use(check well use): L�o ft. +a=ft. SF I
4A t-, in- n.i"a
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
:3Agricultural [3Municipal/Public ft. ir. in
:)Geothermal(Heating/Ccicifing Supply) §oResidential Water Supply(single)
ft, ft. in,
"Ilridustrial(Commercial [)Residential Water Supply(shared) --
-18.GROUT
Irrilation FROM I TO MATERIAL EMPLACEMENT METHOD&XNTOLWT I
Non-Water Supply Well: 0 ft- 20 ft. pumped
. Monitoring [3Recovery
Injection Well:
DAquifer Recharge [)Groundwater Remediation
19.SAND/GRAVEL PACK if savoticable)
Aquifer Storage and Recovery OSaliniry Barrier FROM To MATERIAL I EMPLAHMENTMETHOD
Aquifer Test ostormwater Drainage ft. ft.
Experimental Technology [Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLLtiG LOG(attach additional sheets if necessary)
-,Geothermal(HeatimJ '21 Remarks) FROM _ TO DESCRIPTION color.hardness.soi 1llrock t3lm grain sire.etc.)
Cooling Return) Mother(explain under 0 ft. so f, clay&sand
4.Date Well(s)Completed:40gi- Well ID# 30 ft' 570 ft' granite
Sri.Well Location: ft. ft.
8 Rom+'-s Liz ft. ft.
Facility/Owner Name I Facility ID#(if applicable) ft. ft.
'2% 5U�r 0. g-a. CIX110wh ft. ft.
Physical Address,CUX.6d Zip ft. ft.
3 pe"O.-N Cau-*'-N r7,59 Ci_15-U1(pkp 11-RVNIARKS
County Parcel Identification No.(PINE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees- -
(if well fic1d,one lattiong is sufficient) 22.Certification:
3 5 0 19".A:' N ZEIg4� t-)CL."41 41-1414z
6.Is(are)the well(s)opermanent or DTemporary Signature of Certified Well Contractor Date I
By signing this form,I hereby cerfifi�Ilya/4 F11(s)was(irere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or No svith 15.4 NCAC 02C.0100 or ISA NCAC 02C.0200 Mell Construction Standards and that a
#'tliisisa repair,fillout knotty well coitsinictioninfai-titation 'At explain the nature of the copy of this record has been protided to the well owner_
repairunder 021 remarAw section or-on the back of this fonn. 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 attach additional pages if necessary.
drilled:_ I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5`­70 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi&reiit(ovample-3@200**"and 2@100') construction to the following:
10.Static water level below top of casing: 14 (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: t n.)o a 24b.For Injection Wells, In addition to sending the form to the address in 24a
V above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: - a i , " construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) a-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: bzil� 24c.For Water Supply& IniectionWells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county,health department of the count),
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division ofWatcr Resources Revised 2-22-2016