GW1-2021-06365_Well Construction - GW1_20210915

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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 FRO,NI TO I DESCRIPTION
ft.
V S?-A
' ft. tt.
NC Well Contractor Certification Number 15.OUrER CASING for multi-cased wells OR LINER f o licable)
Hedden Brothers Well Drilling, inc FROM TO DIAMETER THtCKVESS MATERIAL
ft. ft. In.
Company Name
16.INNER CASING OR TUBING'' eothermal closed-loo
2.Well Construction Permit n: 101040?o--j} FROM TO DIgAtETER THICK.ESS MATERIAL
List all applicable well carsmuuction pamirs rte.UIC County,S�tare7Yarim:ce,etc.) 0 ft. ft In. �
3.Well Use(check well use): ft- tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICIG\ESS aIATERIA
Agricultural omunicipal/Public ft. ic. in.
Geothermal(Nenting/Cooling Supply) NResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18 GROUT
D ltri ation FROM TO I MATERIAL EhIPLACEMEVI'METHOD&A.1IOU'.NT
Non Water Supply WeII: 0 ft. 20 fL tensnAev�cc pumped
Monitoring Recovery ft. ft.
I
njection
Test 3StatmwaterDrainage
ection Well: ft ft
quifer Recharge Groundwater Rcmediation 19 SANDIGRA'VEL PACK if applicable)
quifer Storage and Recovery Salinity Barrier FROM TO MATERUL EMPLACEaIE1T 2NIETHOD
ft. rtxperimental Technology Subsidence Control ic. ft.
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets If necessar
FR0�1 TO I DESCRIMB—N 1color,hardness,sot[/rock type.eraln size,etc.)
cothermal(Heatin Coolin Return) Mother(explain under T21 Remarks
fr, CY ipi fL clay&sand
4.Date Well(s)Completed:L Well IDn ft. ft. I granite
$a.Well Location:
tt. ft. [
vi Wood
FaciiitytOwnOwnerNamt Facility ID>:(ifapplicablc)
ra 80cdensvik Mine kd �ra„lUin oZ$7t3y- rt. e. ti 5 2021
Physical Address,
City,and Zip I'� j_�f ,+ +�n ft. 1 it.
A.. S e4fi f 5 3(Y •1743 /9 21.REhLAI KS 31 r .1.
County Parcel tdcntitication NCO.(PIN)
DW ,Qr u
Sb.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(ifwetl field,one lat/iong is sufficient) 22.Certification:
6.Is(are)the well(s) Xpermartent or E)Temporary, Signature of a ifiedWeil Contractor Dat•
By signing this form,1 herebr cent'!that a sell(,r)was(were)constructed in accordance
7.is this a repair to an existing well: orP"&ciplahj
No Iuh)51 NCAC 0?C.41D0 ar ISd rYCAC 03C.0200 Well Construction Standards and that a
)#"this is a repair,fill out knanit well cousintetion Information the nature of the copy of this record has been proridrd to the well under.
repair tender n?i reatorkssection or on rite back ofthisform. 23.Site diagram or additional n'ell details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wets 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 N NIBER of wells construction details. You may also attach additional pages if necessary.
drilled: l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 4 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1'or multiple wells list all depths irdt1ferent(example-3@20t0'a a�and) 10111 construction to the following:
me�
10.Static water level below top of casing: `�`ti-C (ft.) Division of Water Resources,Information Processing Unit,
If waterlalrl is shove Casing,:use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b,For Iniection Wells.. In addition to sending the forrn to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
(Le Well construction method: ( 1 h am ,(Le.auger,rotary,cable,direct push,etc.) construction to the following:��
Division of Water Resources,underground Injection Control Program,
FOR WATER SUPPLY/W'�ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: � 24c.For Water SupDly &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: .mount: completion of well construction to,the county health department of the county
where constnicted.
Fonn GW-I North Carolina Department of Entiranmariml Quality-Division o"Watcr Resourms Revised 2-22.2016