GW1-2021-03472_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (+GW-1) For Internal Use Only:
1,Well Contractor information:
Russell Taylor r * � 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-a ��� X �� � y "' a ft.
NC Well Contractor Certification Number Prov),wttq>�t�1i $ Ct n
�f CI.3 r0 15.OUTER CASING for could-cased wells OR LINER(if a llcable)
Hedden Brothers Well Drilling, l FrtoM TO DIAMETER THICKNESS MATERIAL
ft. ft. In,
Company Name
Q p p 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: 0?10421' qD566 +~J0&P p FROM TO I DIAMETER TRiCKNFSS I MATERIAL
List all applicable nett construction permits f.e.WC,County,Stare,i'ariance,etc.) 0 R• tt. in, a I QO
3.Well Use(check well use): ft. n, in.
i 00
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO ARTERIAL I EAIPLACENIE.NT 1tETHOD S A.ItOLnT
Non-Water Supply Well: O ft. 20 fL aenenaeenmte � pumped
Monitoring ORecovery ft. ft.
Injection"Veil: ft. rt.
Aquifer Recharge DGroundtvatcr Rcmediation 19.SAND/GRAVEL PACK tifapplicablel
Aquifer Storage and Recovery D Salinity Barrier FROM To MATERIA EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology ['Subsidence Control ft. ft.
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under�21 Remarks FROM ft To ft.
clay&sand tcaior,hardness.soii/rack type, rain size,etc.)
V clay 8 sand
4.Date Well(s)Completed: 602 IWI Well ID-, ft. ft. granite
ft.Sa.Well Location; ft.
ft. ft.
FacilitylOwner Name (](�) Facility ID#(ifapplicabic) ft, ft.
ft. ft.
Y5e ki CtxnshieYs 7/1 ft. ft,
Physical Address,City.
c_and
�Zip /�r� �yr�
ow 7 T ! !*a 21.REMARKS
County Parcel Identification No.(PINT
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcli field,one lat/long is sufficient) 22.Certification:
350 07. 354 -9. 091 W t1lze
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor 'lateBy signing this fans,1 herebr tenth,thatdtsrtlis)tray(were)eonat7tcted in accordance
7.Is this a repair to an existing Snell: 0Yes or No pith i5A NCAC 02C.0100 or ISA:vCAC 03C.0700 bell Construction Standards and that a
lfIlds is a repair,fill out known well construction information i explain the nature of the cony gfthis record has been providrd to the well onwer.
repair under 021 renmrks section or on the back of this fonn.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I OW-1 is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
LLA
9.Total well depth below land surface; "T..D (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nulls list all depths ifdifjrrent ti'•iantptr-3Q200'andd 21Q11001 construction to the following:
10.Static water level below top of casing: V y (ft.) Division of Water Resources,Information Processing Unit,
7itvater level is above casing,use"_" 1617 flail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 19 (in,) 246. For Iniection Wells:, In addition', to sending the form tothe address in 240
above, also submit one copy of this form .ithin 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) *51D Method of test; &6z 24c.For}Pater Suppiv&Injection Wells: In addition to sending the form to
'1 the addr-ess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hpe: } f S _ Amount: completion of well construction to the,county health department of the county
where constructed.
Forst GW-1 North Carolina Department of Environmental Quality-Division.of Water Resources Recnsea 2-22-20 i a
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