GW1-2021-00220_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information:
Russell Taylor I- 1VATBRZONES
%Yell Contractor Name FROM TO OkSCRIPTION
21 s7-A 11A ft. ft.
cag fL a ft.YC WeII Contractor Certification Number
Hedden Brothers Well Drilling, Inc FRO 11rrERc Onve eraDIAMEdwelis TM o7R7iLrW aill IAL
Company Name R ft In.
—' 98 y r3 16.INNER CASING OR TUBING geothermal eloseddoo
/) O
2.Well Construction Permit#: G7 ,i 7 FROM To DIAMErER TttrcleMS ntaTSRtat,
Gist all applicable null comnvetion permits(i.e U1C,Cotmry,State.Irarianre,etc.) tt• ft. in.
Pvc
3.Well Use(check well use): ft. W7 ft. 11L S
Water Supply Well: 17.SCREEN s
Agricultural FROM TO DIAMIETER SLOTSIZE TIiICKNESS MIA7ERIAL
OMunicipaVPubfic ft.
Geothermal(Heating/Cooling;Supply) WResidential Water Supply(single)
ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
hti tion Fit TO MkT_ERIA EmP C&*'i "r'*1 touilT
Non-Water Supply Well: n• 20 n• _naewa,s pumped
Monitoring Recovery ft. R
Injection tiVeii:
Aquifer Recharge [)Grotmdwator Rcmediation ft. iL
offer Story a and Recovery 19.SAND/GRAVEL PACK i[a Dr able
Aq g ery [�SaliniryBarrier FROM TO I MTATERIAL EVPLACEMt&\TMETHOD
Aquifer Test Etistormwater Drainage ft. 1L
Experimental Technology [Subsidence Control ft. tL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it neeessa
Geothermal(HeatintlCooling Return) MOther(ex lain under#21 Remarks) FROM I To DESCRIPTiO\(color.hardness to{Uroet twe.Vale Am etca
0 ft, 7 fL clay a sand
4.Date Well(s)Completed: Well ID# 37 h• .925 n• granite
Sa.Well Location: rt• n �-
�en+ p i Y IQ.Siena,. ft. ft. a
Facility/OwncrName Facility iDO(ifapplicable) ft. ft.
nFC
Lm .-A R •i, ft. ft.
Physical Address,City.and Zip ft. ft.
J Cw, -
N?y 21.RE,lL41tICS 1",�:.t
County Parccl ldcmfftcation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlloog is sufficient) 22.Certification:
%350 D7. *15 N _ 0830 06-934 wZE II �a
6.is(are)the weli(s) Permanent or E3Tempm•ary Signature ofCcnified Wei(Contractor Date
By signing this jornr.1 hrrebs•eertlfr that r o711(s/iron psrn)eanstttrcted in aocordanor
7.Is this a repair to nn existing well: MYes or No i ilh 15A NCAC 02C.0100 or 15.9 NCAC 02C.0200 0rll CoartrueBon Standards and that a
jlhtr it a repair,ftli orrr known tvril construction informatlon A.explain the nanor of the copy of this record has been providrd to the aril ourtei.
repair under#21 mnar/s secrioo or on the back ofthis fornr.
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 below land surface: t?75 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For maldphr,sells list all depths ijd ffnent(trample-3Q200'and 2@100.1 construction to the following:
10.Statie water level below top of casing: 30 (ft.) Dlvision of Water Resources,Information Processing Unit,
{fwater/owl is ahane easing,Ilse"+,. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:-, —_(in.) 24b.For Iniection Wells:. In addition to sending the form m the address in 24a
n , y� f ���— above, also submit one copy of this form within 30 days of completion of well
(I. ry,Well construction method:------S.R.�1S i._J �a auger,rota cable,direct push,etc) 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) 50 Method of test:_ 24c.For Water Suoole S Iniection Wells: In addition to sending the form to
i the address(es) 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 county
where constructed.
Form G%V-i North Carolina Department of Emironmamal Quality-Division of Water Rcsourc.s Revised 2-32-2016