GW1-2021-06640_Well Construction - GW1_20211007

VULL CONSTRUCTION RECORD (GW--1) For Internal Use Only: --- — -
1.Well Contractor Information:
Russell Taylor 14.Ii'ATERZONES
FROM To DESCR1PTtO,
A'VetlCanttacforNamc 2187-A 1
0-tn—
�ft, , 0,'Q6
VC Weli Contractor Certification Number a91 ft, °1 q ft,
15.OUTER CASING for multi-eased wells LINE (!f a livable)
Hedden Brothers Well Drilling, Inc FROM TU DIAMETER THICKNESS aATERIAL
ft. it. in.Company Name
16.LWNER CASING OR TUBING eotherml dosed-loa
2.Well Construction Permit a
: 0�0 �...a1D(pai " �' 10�'/o FROM To DIAMETER TRICENEss MATERIAL
List all applicable tvcll constrncllaa permits C,.e.U1C,County,Stare,Marinate,etc.) 0 R• q 4
ft. j In.
3,Well Use(check Weil use): 1 f ". 9 t0 iL �+�' in. . 18
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Manicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. td•
IndustriaUCommerciai OtResidential Water Supply(shared) I&GROUT
irri ation FROM I TO MATERIAL I EBIPLACEItLNTMETHOD tk AMOWNT
Non-Water Supply Well: rt. 20 rt• t�trsset r+� pumped
_,Monitoring ORccoveTy
Injection Well:
.._ AquifcrRechargc Groundwater Rcmediation 19.SAAID/GRAVEi.PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEi1IE\T METHOD
y Aquifer TestOStomiwater Drainage it. ft
Experimental Technology Subsidence Control
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FROM n TO I DESCRIPTION scalar,hardness,selllrock t.train size,etc)
Geothermal(HeatinglCooling Return) - �)Remarks)(explain under ) ft ft
n clay&sand
A.Date Well(s)Completed: 7 o�lb�� Well IDn ft. ft' I granite
So.Well Location: ft. ft. ty„
D04-rell ft. ft.
Facility m//OwnnerNae �i Facility lD9((iif�a-p}plicabic) rt. ft. C �nli
'71O UQ q�"!it_) �V�1fGL A/i /1ab7 ft. ( ft.
]
Physical Address,City,and Zip fr' II ft-
104450M� 75a 8- 49-8,f53 21.RENURKS
County Parcel ldentification No.(PIN)
>b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification: `�
1r]. (A-a N 0836 Ito,1>i lO W �+ff�- � _1�.' i _
6.Is(are)the well(s) Permanent or InTempomry Signature ofcenirred Well Contractor Dat
By signing this fonm 1 hereby certify that r strl/(y was/tare;constmcted in accordance
7.is this a repair to an existing well: nYes or PNo
itith I5A NCAC 02C.0100 or 15d NCAC 02C.0200 hell Construction Standards and that a
/fthis is a repair.fill out knottyWeil construction informationexlain the nature of the coPy ofthis record has been provider!to the it as+mtr.
repair under R21 remarks section or on the back of this faun.
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-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIOI\S
9.Total well depth below land surface: Jz (ft-) 24a. For Ali Weiss: Submit this form within 30 days of completion of wets
For multiple i ells list all depdrs ifdifferent t"erainple-3@200' n a/d12@100') construction to the following:
10.Static water level below top of easing: DV (ft.) Division of Water Resources,Information Processing Unit,
(f water level is above cosing,use"-" 1617 Hail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 19
9 (in,) 24b.For Iniection-Wells-- In addition to sending the form to the address in 24a
--IIYY�� above, also submit one copy of this form within 30 days of completion of well
I2.Well eonstruMioti 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) islethod of test: 24e.For Water Suooh•&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:-- --a amount t? completion of%veil construction to the County health department of the county
where constricted.
Fonn G%V-t ?north Carolina Department of En ironmcntal Quality-Division o:Waicr Resources R..n ised?'2-2016