GW1-2021-00041_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD (GW 1) Print Fo
For Intt:mal Use Only: rm
1.Well Contractor Information:
Russell Taylor Ia.lvaTSRzoivEs
Well Contractor Name FROM I TO DESCRIPTION
2187-A rt. fr.
ft. ft.
VC Well Contractor Certification Number
15,OUTER CASING for multi-used welts OR LAYER a licable)Hedden Brothers Well Drilling, Inc FROM TO DiADiETER THICKNESS MATERU►I
Company Name nn ft. fL In.
2.Well Construction Permit#:0l019" 9- r7/0/� 16.INNER CASING OR T[1BING! eothermal closed-loo
FROM TO DtAatETER THICKNESS DIATERIIL
List all applicable aeit construction pernmts ii.e WC.Cotmoy State,Mariance.etc.) � R. /) ft. ►a. n
3.Well Use(check well use): aZ I ft. q YCI
fL ,n. e 8 Y gF
Water Supply Well: 17.SCREE,v�I
Agricultural MUnicl al/Public FROM TO DIAMETER SLOTSIZE THICi-NESS bATERIAL
p ft. ft. in.
Geothermal Menting/Cooling Supply) Residential Water Supply(single)
ft. ft.
IndusuiaUCotnmercial Residential Water Supply(shared)
hri anon 18.GROUT
FROM TO MATERIAL EMPLACEJIF-TMETHOD S a.NIOL,NT Non-Water Supply Well:
ft. I 20 fL cerrcraer::tc pumped
Monitoring tL R.
Injection Well:
Aquifer Recharge [)Gtoundwatcr Rcmediation ft I it.
Aquifer Storage and Recovery �q Salini Barrier 19.SAND/GRAVEL PACK if a lit able)
LJ ry FRO,% TO SATERIAL EMPLACEMETMETHOD
Aquifer Test ElStormwaterDrainage ft. fL
Experimental Technology Subsidence Control
Geothetmal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necesso )
Geothermal(Heatin CoolineReturn) Other(ex lain under#21Remazks) FRoat To DESCRIPTIONteolor.hardness.soil/roekh a msru,erca
P°; ft, ft- I Uay 8!sand
4.Date Well(s)Completed: aI - Well ID# �3 ft• ft. granite
Sa.Well Location: ft. R.
Facility/0 crNamc Facility iD9(ifopplicablc) NQV
ft. ft• ) �'
'1 I psi r,et-K Rd. �87 I t7 R. ft.
Physical Address,City.and Zip fr. I ft.
J43@ASW e NT� 7573-Ne-9`�57 21.REhL>RKS t' a
County Parcel Identification No.(PIN) _, U
UNi-
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwoll field,one IaUlong is sufficient) 22.Certification:
J5' 0832 11 ,270 W
6.Is(are)the well(s) permanent or 07remporary Signature ofC.-nified Well Contractor ; Date IBy signing this form./hereby eertifp that t ar/lts)nos(were)coastrteted in accordance
7.Is this a repair to an existing well: 0Yes or No nith IJA NCAC Q2C.Q/00 or IS.�NCAC 02C.0200 Il'eq Consmtctiom Standards and thol a
if thin is a repair.fit out known well construction information0axplainthenattereqt"the copy gfthis record has been provided to the well ouwer.
repair under 01 remarks section or on the back ofthis form.
23.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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:__ SUBMITTAL INSTRUCTIONS
9.Total well depth belowland surface: 4nn 5 (rt•) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths i/'di ferent feramrple-3@200'and 1@)00') construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
/.ftvatertenrl is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_(in,) 24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above, also submit one copy of this form within 30 days of completion of well
�T
(i.e.auger,rotary,cable,direct posh,etc. V construction to the following:
Division of Water Resources„Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) 7Z.5 Method of test: 24c.For Water Suouh•6 Iniection Wells: In addition to sendine the form to
i I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: amount: l 0 completion of well construction to the county health department of the county
where constructed.
Form G1V•I North Carolina Department of Enviranmantal Qualiry-Divsion of ivztcr Resources Revised 2-2-1-201 E