GW1-2021-00050_Well Construction - GW1_20211109

Prot Form
WJELL CONSTRUCTION RECORID (GW 11 For Intemal Use Only: - -
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Weil Contractor Name FROM TO DESCRIPTION
2187-A fr. ft.
ft. ft.
NC Well Contractor Certification Number i
Hedden Brothers Well Drilling, Inc FSRU�rrER CASING form D A-easERells OR LINER
K�tESS a 'VATERIAL
Company Name ft. fL in.
1 DD,_n' A 16.INNER CASING OR TUBING eothertosl closed-lop
2.Well Construction Permit#: tlbl Fxoar To DIAMETER Ttnct.�tEss atATERWt,
Ltst all applicable it-ell cotumtctlon pwnurr(.a UIC.Colony.State.Variance,etc.) R. it In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn J3MunicipaUPubfic fr ft. in.
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single)
Industrial/Commercial OResidential Water Supply(shared) ft, ft. iv.
1S.GROUT
Ilrl atit , FROM TO MATERIAL E'N L.CEMEN'T,IfETHOD S LNJOLrN
Non-Water Supply Well: fc• 20 fL rere:aes__,e pumped
Monitoring Recovery It. fL i
Injection Weil
AquifcrRcchargc []GroundwaterRcmediation fr. ft.
Icc.
quifer Storage and Recovery19.SAND/GRAVEL PACK if a livable)
Salinity Barrier FRuiit To JIATEttIAL EJIPI.ACEA(E\T>IETHOD
quifer Test OStormwater Drainageft. ft.
xperimental Technology Subsidence Control ft. ft.
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
eothermal(Heating/Cooling Return) L70ther(explain under'-21 Remarks) FROM I To I DESCRIPTfO�(color,hardness solUrock n r gmin size,etc.)
P°: fr' I fG I clay Ssand
4.Date Well(s)Completed: Well M fr• fr• I granite
So.Well Location: R. ft. i
-
Facitity/OwncrNlame Facility ID#(if applicable) ft. ft.
- Q-11 b s'oO KC Lal t. I-rO-n 0?187 ft. I rt.
- �th
Physical Address,City.and Zip ft. I ft.
_('WMVI 953339(o51-hot. ZI.REMARKS , ,
County Parcel identification No.(PIN �.) � Q
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Well field,one IaVlong is sufficient) 22.Certification:
to I a?off
6.Is(are)the well(s)Permanent or Temporary Signature of Certified Well Contractor i Date
By signing this fo m.1 herebr certify that t itell(s)it=(irerr)eoncimcled in accordance
7.Is this a repair to an existing well: FlYes or No ttith 15.4 NCAC 02C.0100 or 1S.d NCAC 03C.0700(Fell Construction Standards and that a
ythis is a repair,fill out known well construction informationpo-explain the nature afthe copy of this record has been provided to the hell ouner.
repair under 921 remarks section or on the back-of thisfarnt.
23.Site diagram or additional well details:
9.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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 , SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: e7'%"'� (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple rrells list all depths itdii ferew hxample-3@200 and 3QI00') construction to the followine:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
{/water/curl is above casing,nsr":" 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
1•- above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_a Li construction to the following:
04.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 K
13a.Yield(gpm) •V Method of test: 24c.For Rater Suonly S Infection Wells: In addition to sendine ilia form to
t the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: amount: completion of well construction to the county health department of the eounn•
v where constructed.
Form G%11-1 North Carolina Department of Entiramnamal Quality-Divisio.n os%Cater Resources Retised?22-2016