GW1-2021-03471_Well Construction - GW1_20210607

i,
Print Farm
WELL CONSTRUCTION RECORD (OW-1) For Internal Use Only. r
I
I.Well Contractor Information:
Russell Taylor RE D `�
14.1VATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
2187-A 'V� X 7 7751- ft.
-n ssing uv)"
VC Well Contractor Certification Number 11'�10TIT.U 1011 per i Ig,OUTER CASING for multi-cased welts OR LINER(if applicable)
Hedden Brothers Well Drilling, Inc Ci'v"� sec `�� FROM-FT-0 DIA51ETER THiCKNESS I MATERIAL
ft. ft.
Company Name
n/� ,,�,gyp6.LINER CASING OR TUBING eothermal ciosedloo
2.Well Construction Perm Aft#: t- 1901,79- Cl"q0 1 FROM TO DIAMETER THICK-NESS MATERIAL
List all applicable welt construction permits(i.e.UIC,County,State,rrariance,etc.) rt. ft. In. • 'pp 57V
EL
3.Well Use(check well use): ft. it. in. 0 0
Water Supply Well: 17,SCREEN
FROM TO DIAMETER': SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft, ft. inJ
IndustriaVCommercial DResidential Water Supply(shared) ill.GROUT
Itil orlon FROM TO I MATERIAL EdFPLACEMENT METHOD S AMOi NT
rAquifer
er Supply Well: ft. 20 tL 4 t1Ep� pumped
ring Recovery R. it.
Injection tiVell:
Recharge [)Groundwater Remediation fr. fr.
19.SAND/GRAVEL PACK if a livable)
Storage and Recovery Salinity Barrier FROM TO NATERIAL EMPLACEMENT METHOD
Test [DStormwater Drainage ft. ft.
ental Technology Subsidence Control ft. ft.
tal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if aecessar)
mal(Hearin JCooiing Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION icotor,hardness,soil/rock n r, rain sin,etc.)
... ft- clay 8 sand
4.Date Weil(s)Completed:�J �) °(� Well ID# C
ft. $� ft. granite
So.Weil Location: fc, ft.
Facililiitty/�O[tw"cSr NNlame II p J Facility IDn(if applicable) ft. ff.
s711� [ •� GY k Rd. Cd1 ftgxe ft. ( ft. )
Physical Addres. iitty,and Zip �+� ft. ! It.
n JAf�14'Sc�l/ ! wrq:d 15gq
l� 21.REMARKS
Q a iRKs
County Parcel Identification,No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwc(i field,one lat/long is sufficient) 22.Certification:
350 19, tea N 83 0-9s !b2!5 W �� At2 5 as - oaI
6.Is are the well 5 Signature of Ccniticd Well Contractor Date
Is(are) well(s) or
By signing this form,i hereby certJ6-that i irell(s)was(were)conanueled in accordance
7.Is this a repair to an existing well: OYes or No isith l5A NCAC 02C.0100 or IS.i NCAC 02C.0200[Yell Constnhction Standards and that a
if ttis is a repair,fill out knottvh Nell canslniction infat'Ination hexplain the nature ofthe copy of rhis record has been provided to the.well ouwer.
repair tinder 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page td provide additional well site details or well
construction,only I i W-1 is needed. Indicate TOTAL NUMBER of wells consuuction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1000 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of+veil
For multiple irells list all depths ifdi))erent teranhple-3@ 200'and 2@1009 construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,Information Processing Unit,
Ilwater level is above casing,use••-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 0 _(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:_ t� h . construction to the following:
(i.a,augur,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4lethod of test 24c.For Water Suoaly&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: Amount: completion of well construction to the'county health department of the county
where constructed.
I
Font G11'-t North Carolina Department ofEmironmemal Quality-Division of Water Rcsources Revised??2-?U i 6
's
ly