GW1-2021-06639_Well Construction - GW1_20211007

=: Pr(Iit Farm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -- -
1.Well Contractor Information:
Russell Taylor 14.NVATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2I87-A &q ft. c734 ft.
YC Well Contractor Certification Number 15.OUTSR CASING for multi-cased wells OR LINER(if a lI able)
Hedden Brothers Well Drilling, Inc FROM TU DIAMETER rsltcx,IFss MATERIAL
ft, ft. ln.
Company Name
8oJ 16.DINER CASING OR TUBING eotfiermsl doled-loo
2.Well Construction Permit"R_ _ FROM TO DuatETER TFRCK:'VESS AIATEnIL
Llsr all applicable u^e11 co istraction petanits C.c.UIC.Coratty.State,Parraace.etc) 0 In. . 11819
3.Well Use(check well use): ft. fL In.
Water Supply Well: 17.SCREE;
FROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
_ c al/Publi
Agricultural Munici
P ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMEN7METHOD d`AMOi1NT
Non-Water Supply Well: Coo) ft. 20 It. eemendtanrta pumped
Monitoring Recovery
I
ection Well: I
ft. ft.
quifer Recharge QGrounciwatcr Remediation
19.SANDIGRAVEL PACK if applicable)
quifer Storage and Recovery Salinity Barrier FROM TO NIATERLII EMPLACEM07 METHOD
quifer Test OlStormwaterDrainage ft, ft.
xperimental Technology Subsidence Control ft. ft.
eothermal(Closed Loop) Tracer 20.DRILLING LOG attsch additional sheets if necessa )
eothermal(Heating/Cooling Return) Other(ex lain under 21 Remarks) FROM TO I DESCRIPTION tcolor,hardness,sall/rock type.craln site.ete.)
��]] a
it" I f6 clay&sand
4.Date Well(s)Completed: "7 a-I Well ID# ft. ft. granite
Saa..Well Location: tt. ft.
i)�5 ft. ft.
Facility/ wncr Name Facility ID#(if applicable) ft.
1rZ �u,r►tise. Parr, 5' a ft.
Physical Address,City,and Zip }J t �*�( q tt. ( ft. 0,31 r• 4l,
r7&+
' SUN i�7datt7'f�I l—44-67 1OS 21.RENIARKS
County Parect identification No.(PIN-)
Sb.Latitude and Iongitude in degreestminuteslseconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification:
36o .24.39to N 083° 18.6W w Z�& �J 8 al
d
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
T� By signing this jann.I herebr certift�thatar.r11(s)ttas Are re)Constructed in accordance
i
7.Is this a repair to an existing well: nYes or No fitful lid NCRC 02C.0100 or LS4 NCAC 03C.020o lveli Construction Starndards and dial a
Ifthis is a repoir,fill ont knotm ivell construction information t explain the nature of the copy of this record has been provided to the well owner.
repair under m?I rrmorks section or oil the back of this farm.
23.Site diagram or additional well details:
S.For GeoprobelDPT 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 CAW-1 is needed. Indicate TOTAL NUIr1BER of tvclls construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �t7y (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far muhiple.wells list all depths ifdii ferent fPvantplr-3@200'and 2@100'1 construction to the following:
10.Static water lewd below top of casing: *D (ft.) Division of Water Resources,Information Processing Unit,
)(water level is dhow casing,lisp'_" 161711ail 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: z construction to the following:
(i.e.auger,rotary,cable,direct push,ctc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen•Ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I I_ Nlethod of test: 24c.For Water SuDDIv S Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h a 1 Amount: l f1 completion of well construction to the county health department of the county
where constructed.
Form GW-I ?Forth Carolina Department of linuironmcnt;l Quality-Division of Watcr Resources Revised 2-22-2016