GW1-2021-01605_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2187-A 35 ft. ft
ft. ft.
VC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLLINER(if a llcable
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: .10al-a0384-9- FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC.County.State.Variance,etc.) ® ft. /l,/_ ft. to ✓e
3.Well Use(check well use): 21#o ft. 4 ^T ft. /_ in. •'8$ TI�v�L
Water Supply Well: 17.SCREEN W
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMtmicipal/Public ft. ft, in.
Geothermal(Heating/Cooling Supply) EgResidential Water Supply(single) ft. ft.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD d:AMOUNT
Non-Water Supply Weil: ® ft• 20 fL ..m.man.­ pumped
Monitoring DRecovery
Injection Well:
Aquifer RechargeGroundwatcr Rcmediation
19.SAND/GRAVEL,PACK if a licable
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION 4eolor.hardness,soll/rock type.grain size,etc.)
ft. 14
/ ft. clay 8 sand
4.Date Well(s)Completed: .3 ' o?OQI Well ID# I-} ft. 100 ft. granite
Sa.Well Location: ft. tt. ,4 e,� J J
PAUjL Rock LLc
Facility/Owner Name Facility ID#(if applicable) ft. ft. A
PR
N00n,5+11ne-. L00o (t aSh Ie*. S o? 8 717 f. I ft.
Physical Address,City,and Zip 1 ft. I ft.
t,Acy� tLu.au 75/yD-50- 7159 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
350 03. aa5 N 08A- 0'7 . 509 W
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Datc
"`fff 111 By signing this farm.I hereby cert that t well(i)was(were)constructed in accordance
7.is this a repair to an existing well: E]Yes or No with 15A NCAC 01C.0100 or 15.4 NCAC 01C.0100 Well Construction Standards and that a
/f this is a repair.Jill out knout well construction information hexplainthqnaturrofthe copy of this record has been provided to the well oxuer.
repair under k11 remarks section or on the back of thisjonn 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-1 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: 1000 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple trells list all depths ifdierent(exa iple-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 300 (ft.) Division of Water Resources,Information Processing Unit,
1f rvater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells In addition to sending the form to the address in 24a
, � above, also submit one copy of this form .vithin 30 days of completion of well
12.Well construction method:_( J 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) 3 Method of test: 24c.For Water Suooly A Iniection 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 hype: Amount: completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-201 b