GW1-2021-01606_Well Construction - GW1_20210404

` Print Form:. ;A
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 5
rc. o rL
4/0 ft. ►, ft.
NC Well Contractor Certification Number 15.OUTER CASING for mull-casedlwells OR LINER(if a Iteable
Hedden Brothers Well Drilling, Inc FROM I TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
,i r^
4 16.INNER CASING OR TUBING ebthermal closed-loo
2.Well Construction Permit#: AOAD` 19 118"q r I o� l FROM To I DIAMETER I THICKNESS MATERIAL
List all applicable well construction petvuits(i.e.UIC,County,State,Variance,etc.) ft. 445 ft. in. o e
3.Well Use(check well use): Of ft. �( IL
in. Q (
` e a
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrt ation FROM TO MATERIAL EMPLACEMENT 51ETHOD&A-MOUNT
Non-Water Supply Well: 0 R• 20 tt. c.,.m,&be . pumped
Monitoring Recovery ft. fL
Injection Well:
__Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. %
Experimental Technology DISubsidence Control ft. fL
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(ex lain under 121 Remarks) FROM TO DESCRIPTION Icolor,hardness,solurack n e, rain size,etc.)
n , ft. ft. Gay&sand
4.Date Well(s)Completed:*/�1 Well ID# i tt. �ft. granite
Sa Well Locatio / fr.
;Ma & ue,
Facility//Onwnnee'rNeame Facility iD#(ifapplicable)
IJ Q 7/
ysieal Address,City,and Zip �h//��//� ft. ft nt,cu�,�cll e(�li`i�l
1�/_O 1 /6�"�_ Z1.REMARKS ii3v~ � e•.f r^.0(`i' I1
C unty Parccl Identification No.(PiN)
5 .Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
lfal� CL ojl
6.Is(are)the well(s)aperinarient or OTemporary Signature of Certified Wcll Contractor Date F if
��,,(t, By signing this faun,I herebv certify thatawell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Consintction Standards and that a
Ifthis is a repair,fill out known well construction information explain the nature ofthe copy ofthis record has been provided to the it-ell owner.
repair under#21 remarks section a•on the back of this form.
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-I is.needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1100 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 3uc76 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is abom casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For lniection 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: L �l, 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 Suppiv&Infection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of later Resources Rcviscd 2 22-2016