GW1-2021-06823_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information: 1. e!D
Russell Taylor 14.NVATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2187-A 19-0 145
NC Well Contractor Certification Number ft. 14,
_ 308 " 751-L*3
15.OUTER CA
SING formulti-cased weft)
Redden Brothers Well Drilling, Inc PB�L�ER1114P licable)
TWICV'ES'
DIAMETER MATERIAL
Company Name ft. I In.
16.INNER CASING OR TUBING feeothermal closed400D)
2.Well Construction Permit#: FROM TO I DIAMETER I TmCk-_'VF_sS I 'MATERIAL
List all appilrable ive/I construction permits Cl.c.07C,County,State,Variance.etc.) ft. 12. ft. (S In. 0.1 srg
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM _ TO DIAMETER SLOTSIZE THICKNESS MATERIAL
:)Agricultural MMunicipaMblic
lGeothermal(Heating/Cooling Supply) O-Residential Water Supply(single) in.
IIndustrial/Commercial 0Residential water Supply(shared) 18.GROUT
nIrrigation FROM I TO MATERIAL EA I P L A C EN I E N,TMETHOD AMOUNT
UNT
Non-Water Supply Well: -0 ft. 3A ft. pumped
Monitoring DRecovery ft. ft.
Injection Well: -
Aquifer Recharge DGrounclurater Remediation
19.SAND/GRAVEL PACK ft applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO T MATERIAL J_EMPLACEMENTMETHOD
Aquifer Test 0stormwater Drainage ft. fr
Experimental Technology OSubsidence Control rt. ft.
Geothermal(Closed Loop) [Tracer 20.DRILLING_LOG(attach additional sheets if necessary)
Geothermal FROM TO I DESCRIPTION'lcolor.hardness,soil/rock t�'pe. rain sim.etc.)
1� _f Other(explain under"
al(HeatinjCooling Return) 21 Remarks) 43 ft. 4A f, day&sand
4.Date Well(s)Completed: 13 Well ID,"
- 60_601tt. � granite
Sa.Well Location: it. ft.
_D&iol 30ex ft.
Facitity/OwnerName Facility ID#tif applicable) ft. ft.
400 Cherqwood tone- 14i4land-s oUT41 - - ft. ft.
City Zip Physical Address. 11.) 1 ft. ft.
me'"'i 1 46-o?140 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
_850 +44
Signature of Certified Well Contractor ate
6.Is(are)the well(s),Xpermanent or OTemporary /F 4A
8),signing this Jana,I hereki,cerfifi!that ivell(s)is-as(Sven)constructed in accordance
.1L
7.Is this a repair to an emsting well: Dyes or No isith ISA NCAC 02C.0100 or IS.4 JVCAC 02C.0200 Well Constriornon Standards and that a
trthis is a repair,fill out knonn ivell construction information Aul�explain the nature of the copy of this record has been prorided to the uvll on-ner.
repair under#21 reniarks section or on the back of this foray. 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: &00 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple,cells list all depths Jfdifferent(kraniple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing; (ft.) Division of Water Resources,Information Processing Unit,
ffivater level is above casing,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 fbliovting:
(i.e.auger,rotary,cable,direct push,etc.) U
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) r) Method of test: boo 24c.For Water Suppiv& Iniectioni Wells: In addition to sendine the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t 1 Amount: completion of well construction to the count),health department of the county
where constntcted.
Form GW-1 -North Carolina Department of Emironnicnial Quality-Division ot"Watcr Resources Raised 2-22-2016