GW1-2021-06919_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Informat[on:
�,-^.A
—Russell Taylor t^ SY! ��, 14.WATER ZONES
Well Contractor Name 9 w s� FROM I TO I DESCRiPTION�L'i
2187-A �/ �/ q ft. 140 ft. 4 b-T"°l`p
A � L��� � ft. /_ ft. -
INC Well Contractor Certification Number 6G0
r^'�, tar r^ft;�Slrf�gjy S.OUTER CASING for'muId-cased walls OR LINER{ifa lieabie)
Redden Brothers Well Drilling, Inc I137.i1�.�sru°i ���tGB FROb1 TU DIAMtETER THiCK.YESS MATERIAL
ft. ft. in.
Company Name
q p �y 16.INNER CASING OR.TUBING eothermal closed-Too
2.Well Construction Permit#: dogo - I!6 f0 7 98 FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable{tell construction permits(t.e.WC,County.State.Variance,etc.) 0 ft. 9 ft. /„ In. `r(►
3.Well Use(check well use): R. I i ft. u' in. ` .v�L
Water Supply Well: 17.SCREEN
FROM TO DIAMtETER SLOT SIZE THICKNESS MSATERIAL
Agriculnual C&Municipal/Public ft. ft. in.
Geothermal(14eating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) i>).GROUT
Irrl ation FROM TO MIATERIAL I EMIPLACEMiENT MtETHOD S A.ttOUNT
Non-Water Supply Well: ft. 20 ft. ,,k,;,,,,, pumped
Monitoring . Recovery ft ft.
Injection Weil:
Aquifer Recharge OGrouadwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery O-Saliniry Barrier FROMTO MIATERIA EMiPLACEMIE\-r'MiETHOD
Aquifer Test Ostormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft t
Geothermal(Closed Loop) Tracer 20,DRILLING LOG(attach addltronal sbeets if necessary)
FROM TO DESCRtPTtON{color•hardness,sollrrock tv e, min size,etc.)
Geothermal(HeatinglCooling Return) MOther(explain under#21 Remarks) ft C.- R
clay S sand
4.Date Well(s)Completed: e170+Z !!'el!ID# ft. QO ft. granite
Sa.Well Location: ft. it.
Ct. ft.
Wt a'f1 T=M eJlr _
Facility/Owner Name Facility ID#(if applicable) ft. ft.
419 dD ia•4nd n i dQe, Rd. ilk hi-Wier o?8 1 9 rt. rt.
Physical Address,City.and Zip
t,,,�It`1L`k,SOtrJ C.ouarY r'��r�i ,��)a e��,y,5 21.REIL4RICS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
350 ow. 95Af N 0"* 110.q -5 w ! 4
6.Is(are)the well(s) permanent or EiTemporary Signature of Certified%Veil Contractor pate
By signing this form,1 herebv certi�that u it-elf(s)was(were)constructed in accordance
?.Is this a repair to an existing well: nYes or NG with 15.4 NCRC 03C.0100 ar 15.4 NCAC 0?C.0?00 tleA Conslrrction Standards and that a
If[his is a repair,fill out knomi swit construction informationA.&1explain the nature of the copy of this record has been provided to the well curter.
repair under 92/rentarlrsection or on the back ofthisfonn. 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 fW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: J SUBMITTAL INSTRUCTIONS
9.Total w t�ell depth below land surface: 100 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple,vel/s list all depths iit dAerew rerawple-3@200'atand 2©1001 construction to the following:
10.Static water level below top of casing: 90 (ft.) Division of{rater Resources,Information Processing Unit,
I(water level is above casing,use"-" 1617!•Tall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:! C� (in.) 24b. For Ingestion 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: �a �— — construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) V
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: boo 24c.For{rater Supply& Injection Wells: In addition to sendinc the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hype: _ amount: completion of well construction to the county health department of the county
inhere constructed.
Form GW-i North Carolina Department ofEmironmcntai Quality-Division of Water Resources Rat'tsed 2-22 2016