GW1-2021-06647_Well Construction - GW1_20211007

_
WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only: Print Farm
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
ft. 0.l.fl ft,
2187-A ir. 1 ..r786 fc
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells ORLINER(if a ]icable)
Hedden Brothers Well Drilling, Inc FROM To DIAMETER THtt KNEss MATERIAL
[t, fL in.
Company Name
Q n�9(„� r rj 16.LINER CASING OR TU13IIVG(geothermal closed-loop)
2.Well Construction Permit#: l' FROM To I DUAIETER THICI..YEss I MATERIAL
List all applicable will construction permits(.e.UIC,County.State,Irariance,etc.) 0 R. tt In. ,g8 3
-re-61'
3.Well Use(check well use): ft. ft. in. ;
Water Supply Well: 17. REEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipallPubfic ft. ft. In.
Geothermal(Henting/Cooling Supply) MResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL Ea1PLACEttE17 1ILTHOD&A.AIOL1T
Non-Water Supply Well: ft. 20 fL cerssaenrae pumped
Monitoring Recovery ft. rL
Injection Well:
Aquifer Rccharge E)Groundwatcr Rcmediation ft. I fL
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DiSalinity Barrier FROM TO 1 SIdTERIAL E.1IPLACE, F-T METHOD
Aquifer Test 0-Stormwater Drainage st. ft
Experimental Technology Subsidence Control fr. ft.
Geothermal(Closed Loop) Tracer 20.DRILLLNG LOG fartach additional sheets if necessary)
FROM TO I DESCRIPTION(color.hardness.soittraek t e.erain size,eta.)
Geothermal(Hearin Cooling Return) Other(explain under r21 Remarks) � fL clay 3'sand
4.Date Well(s)Completed: 7 ) Well ID;r J,3 ft' 650 n' granite
Sa.Well Location: `' ft. ft. "�
-� 1" ft. ft.
FaeilitytOwn Q{Name Facility IDR(if applicable) ft, ft.
Arlip Uw-x- l*-w X.Zd- 1 $ ft. it. B�51ri9
Phhfyy�sica��l Address.City,and Zip 4� 2! /}Q t� ft. � ft.
�.iAtori COUtJT`1 I�"IDoi-r 1.5._ 31.R£4L4RICS
County Parcel identification No.(PIX)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well frcid,one lavlong is sufficient) 22.Certification:
-39 0 12.650 N 8.30 ]&.+!!a W 2':g�o� '.3
6.Were)the well(s) Permanent or 01remperary Signature of Certified Well Contractor Date
By signing this farm.I he.rebr certfvlthat r w•elIes)was(mere)con tnicted in accordance
7.Is this a repair to an existing well: )Yes orParlain
No with 15.4 NCAC 02C.0100 or ISA NCRC 02C.0200 Irell Constriction Standards and that a
tjthfs is a repair,fill Dirt known,velt eonstntctian inforrrtarton the nature.of the copy ofthts record has been provided to the well awnrr.
nepairntrder#?1 ren+arkrseciion or aYthe backoftltisfon)i. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You rtray use the back of this page to provide additional well site details or well
construction,only) GW-1 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)and surface: 850 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nurltiple trells list all depths tfdierent(prmnple-3@?00'''attr__rd 3@100') construction to the following'
10.Static water level below top of casing: 40- (ft.) Division of Water Resources,Information Processing Unit,
Iftvater level is show casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection!Fells: 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 we))
12.Well construction method: (�Lei . construction to the fallowing:
(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) .__ Method or test: 24c.For Water Suonh•&Iniection Wells: In addition to sending the-form to
the address(es) above, also submit one copy of this fort within 30 days of
13b.Disinfection type: _ Amount: d complction of well constriction to the county health department of the county
where constructed.
Form Gtt'-1 North Carolina Department of Entiranmeniai Q=lity-Division of Water Resources Reused 2-32-2016