GW1-2021-01585_Well Construction - GW1_20210309

'Print Farm`_
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor R, F;r.F:IVED 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A �41�� 2�2� 35ft fr.. $eft.
ft.
NC Well Contractor Certification Number Unit
15,OUTER CASING for.muld-cased wells OR LINER(if a licable
Hedden Brothers Well Drilling lq4grmatlon Processing Unit FROM I TO I DIAMETER T THICKNESS MATERIAL
pWR Section tt. ft. In.
Company Name
..`` �1
16.INNER CASING OR TUBING eothermal eInwd-too
2.Well Construction Permit#: LORZ -I O( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yo•iartre,etc.) ft, rL In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSi'LE THICKNESS MATERIAL
�Municipal/Public ft. I ft. I in.
Geothermal(Beating/Cooling Supply) Residential Water Supply(single) ft. I ft. in.
IndustriaUCommercial iDResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&A.\10UNT
Non-Water Supply Well: ft. 20 ft* dea pumped
Monitoring MRecovery
Injection Well:
Aquifer Recharge E)Groundwatcr Remediation
:)Aquifer Storage and Recovery 19.SAND/GRAVEL,PACK if a licable
q $ ry �tSalinity Barrier FROM To MATERIAL I EMPLACEMENT NIETHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,seiltrork type, min size,etc.)
,, ft. fL clay 3 sand
4.Date Well(s)Completed:-4 _ Well ID# ft. ft. granite
Sa.Well Location: ft. ft.
Lind0. �"1t�uAsd1-Fbhstr e. rt.
Facility/Owner Name Facility ID#(ifapplicable)
o?9 b ag247
�Phy-siiccaall Address,City,and Zip 0 1
ft. ft.
�rAt[511'�11i0. " 21.REMARKS
Coun-ty I Parcel Identification No.(PIN) 1 1 r7, m /b51
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/Iong is sufficient) 22.Certification:
350 0r7•r795 N _085' 04. I9Le W
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
TTT��� By signing this form,I herebv certo�-that u well(s)wav(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No ivith 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ijthis is a repair,fill out known well construction information Pexplain the nature ofihe copy ojthis record has been provided to the well owner.
repair under k11 remarks section or on the back ojthis join.
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 t GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if trecessary.
drilled: I 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 00V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijd &rent(arannple-3@200'Ord 2Q100') construction to the following:
10.Static water level below top of casing: 1315 (ft.) Division of Water Resources,Information Processing Unit,
Ijtvare,level is above caving,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 copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(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.Yield(gpm) Method of test: 24c.For Water SuDDiv&Iniection Wells: In addition to sending the form to
t1 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 county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016