GW1-2021-06646_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER zaNES
Well Contractor Name FROM TO I DESCRIPTION
Q2 ft. ft.
218T-A 188
ft. fr.
NC Well Contractor Certification Number 15.OUTER CASMG for multi-cased wells)ORLINER(if a lieableI
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICtO S ntaTEtitAL
R. fL Company Name in.
16.INNER CASING OR INCTIIH feeotherrani closed-Ioo
2.Well Construction Permit fr:_ � J7 FROa1 TO DWMETER TMCk�tEss MATERLIL
L/st all app/lcabte IM11 conrtntellon perniiis rKe.WC,County.State,Ifirfance,etc.) R• Q 1 R, In.
3.Well Use(check well use): ft. 3 ftto
Water Supply Well: 17.SCREE,'v
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMsmicipal/Public ft. ft. th.
Geothermal(Hesting/Cooling Supply) Residential Water Supply(single) ft. ft.
IndustriaVCommercial DResidential Water Supply(shared) i
18.GROUT
Irrigation FROM TO tATERIA4 EStPLACE�SE�7dtEfHOD S A. IN
Non-Water Supply Well: 0 ft. 20 ft. ee�x.arr__,a } pumped
Monitoring C3Recovery ft. ft.
Injection Well: tt ft,
Aquifer Recharge [30roundwatcr Rcmediation
19.SAND/GRAVEL PACK if a llcable)
Aquifer Storage and Recovery �Sa€inity Batricr FROM TO MATERIAL E}IPLACEhIE.\7 METHOD
Aquifer Test R. I. I I
q �Stomtwater Drainage
Experimental Technology Subsidence Control rt. ft.
Geothermal(Closed Loop) Tracer 20.DRILLL\G LOG(nttacb additional sheets if neeessa )
Geothermal(Heatin Cooling Return) --Other(explain under",21 Remarks) 110.1 To l DESCRIPTION(Color.hardness.satVroek n a grain stu,etc.)
p, ft. 2.:7 f4 4{ day&sand
4.Date Well(s)Completed: Well ID* t� ft. ft, granite'
Sa.Well iLocation:
R. ft.
Da�t7y- mC!'Y* ft. ft. 9'-
Facility/OwncrNNamc Facility lD#(ifappiicablc) ft. ft. Colo 14
'7I h j E.W t nf, F OLAWiri ft. It.
Physical Address.City,and Zip 1- fr. ( ft, l v(1\
Aeon- 753410(a45} 21.REX-UMS
County Parccl identification No.(PIN) Or aCytO
3b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(ifwall fic)d,one Iat(long is sufficient) 22.Certification:
/ewa� t3 O_A!i
6.Is(are)the well(s)`f"�' permanent or QlTemporary Signature of Certified Well Contractor Dat9F !
By signing this form.)hereby certify that t ter/list rear(ivme)eonrtnteted in accordance
7.Is this a repair to an existing well- n Yes orAxplain
No idth I3d NCRC 0?C.0100 or IS,I,vCAC 0?C.0200 T e7J Constnteilon Standards and that a
If this is a repair,fill out knonrn tvrll eotisirttction information the nature of ihe• copy ofthis"cord has been provided to the ue/l ouaer.
repair under 921 rvmant;r section or on the back of this form.
13.Site diagram or additional well details:
S.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 INSTRUCT-1 Z<S
9.Total well depth below land surface. 0(0( (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nialliplr nrlls list all depths ifdiJjerent(ermnplr-3@2
�0y0'and 2@1001 construction to the followine:
10.Static water level below top of casing: a lJ (ft.) Division of Water Resources,Information Processing Unit,
1(evalerlevel is above casino,use +" 1617 flail 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 fonn within 30 days of completion of well
12.Well construction method: 1�t, �'� construction to the following:
(i.e.auger,rotary,table,direct push,etc.)
Division of Water Resources,Underground Injection Control program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,VC 27699-1636
13a.Yield(gpm) V� it3ethod of test: &6o 24c.For Water Suooly S Injection Yells: In addition to sending the fonts to
( r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: a: amount: t t I) completion of%veil construction to the county health department of the count),
%%•here constructed.
i
Form GW-I -North Carolina Department of Etni:anmanesl Quality-Division of Rater Resourc,:5 Revised