GW1-2021-06817_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 DESCRIPTION
2187-A
D ft. ft.
ft. Oft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if a ticable
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
n^L(Q 16.INNER CASING OR TUBING eIothermal closed-loop)
2.Well Construction Permit#:- AL ! - 133 8 L q •I 0q 5(0 FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits 6.e.UIC,County,State,Irariance,etc.) ft• O ft. in.
3.Well Use(check well use): 0 ft. 11. In. /
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. I ft. in.
Geothermal(Heating/Cooling Supply) JResidential Water Supply(single) ft. ft. in.
IndustriaUCornmercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. ,bob-m pumped
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge oGroundwatcr Remcdiation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology Ogubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/C oling Return) M Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock h e,gnin size,etc.)
/! � 1 Ct. ft. clay&sand
4.Date Well(s)Completed:1 / Well ID# a ft. OD ft. granite
Sa.Well Location: T ft. ft.
ft. ft. I :0
Facility/ rNam Facility lDR(ifapplicable) ft. ft. l stir
ft. ft. 021
Ph ical Address,City,EQ Zip 40
�.//11�' Qry Q/��/y ft. ft.
_./ 4 4/ / -L 6/! 21.REILkRK5 ?:r� i�ru.�..:�::J.
CouAtitude
Parcel Identification No.(PIN) Oa,r, Cri fill
5b. and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
v 5 ► . !9to N CbS '07, /81 W
6.Is(are)the well(s) Permanent or 07remporary Signature of Certified Well Contractor Date
By signing this joon,I hereby certify that n %vell(t)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or No ivith 15A NCAC 02C.0100 or IS4 NCAC'02C.0200)fell Construction Standards and that a
!'this is a repair,jilt out known well construction it fornmtion explain the nature ojthe copy ojrhis record has been prodded to the+cell o»ter.
repair under QI remarks section or on dte back ojrhis fonn.
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 1 GW- 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: 00 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple nvells list all depths if'di erent 1exannple-3@300'and 2@100') construction to the following:
10.Static water level below top of casing: �v (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:. In addition to sending the form to the address in 24a
^ ' 1 above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �I✓ 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) O Method of test: 24c.For Water Suppiv&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 type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GWI North Carolina Department of Environmental Quality-Division of Water Resources Revised??2-2016