GW1-2021-00223_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WA77RZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A ft, 90 f
636
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welts OR LINER cable
Hedden Brothers Well Drilling, Inc FROM T tf
IAatETER TH,cttvEss MATERIAL
ft. In.
Company Name
16.INNER CASING OR TIMING(geothermal dosed-1oo
2.Well Construction Permit: J&q1 c?17id3-9- )133& FROM I To ULMEMIL I AIATBRLIL
List all applicable moll consinactlon permits rr.e-UIC,County,State,Variance,eta) R. ! R lo.
I PVC
3.Well Use(check well use): ft,
ft. in, gL
e
Water Supply WeU: 17.SCREEN
FROM TO DIVMR SLOTSIZE I THICi6\FSS MATERIAL
Agricultural [3Mtmicipal/Public ft. ft. in.
Geothermal(Henting/Cooling Supply) Mikesidential Water Supply(single) ft. ft. in.
IndustriaUCommercial 131kesidential Water Supply(shared) 18.GROIIT
Irrigation FROM TO MATERIAL I Eb1PLAC XM-rAIETH0V tit AM0Lr,1T
Non-Water Supply Weil: 0 rL 20 M ren.na'tes a pumped
Monitoring Recovery ft. rL
In ect(on Well:
Aquifer Recharge E]Groundwatcr Rcmediation ft, ft.
ntfer Storage cry 19.Sr4�iD/GRAVEL,PACK ff a Hcable
Aq ' rage and Recovery DISalinity Barrier FRoM TO I StAnPJAL I rMPLACEn10-17 M dD
Aquifer Test E33tormwater Drainage ft. f<
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRMIJNG LOG attach additional sheets if necessary)
Geothermal(Hearin Coolie Return) MOther(explain under#21 Remarks) FRoatI To DESCRIPTION tcotor.hardness.soittrad; e gmin Am eta)
fr. TJ (L day S sand
4.Date Well(s)Completed: 11 lr1 a6�) Well IDR ft. ft. gmnite
So.Well`Looccation: ,, R. ft.
B,LIO Iur anel l ft. ft.
77,
Facility/OwncrName Facility ID*(ifapplicabic) ft. ft.
Q J' n R. ft. 1
Physical AddressCity.and Zi ft. ft � _ -. S •
County Parcel identification No.(PIS)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field.Otte latllong is sufficient) 22.Certification:
35° 69. *1 N -D83° 10•rl 84 w
1E1-L1a1&P-ff
� 1
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Weil Contractor Date
By signing this form.i hrrebr eertif-that urH(sl it-as(it-err)constructed in aacordarter
7.is this a repair to an existing well: Mes or NO pith 15.4 NCAC 02C.0I00 or I51 NCAC 02C.0200 li'ell Consintedon Mandardt and that a
ythis is a repair.JH1 oar knon7r will construction information tdesplain the natare of the copy of this record has been provided to the hell owner.
repair under#21 remar a section or on the back of this fort.
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 1 OW-1 is needed. Indicate TOTAL NUh1BER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: &00 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple arils list all depths ifdder ent itrarnple-3@200'and 2@1001 conswction to the following:
10.Static water level below top of casing: ���b (ft.) Di dsion of Water Resources,Information Processing Unit,
16vater level is above casing,use 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wells. In addition to sending the form to the address in 24a
t_ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Liconstruction to the following:
(i.a.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Sen'ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method ortest:-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
i the address(es) above, also suiimit 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.
Fonn ow-I North Carolina Department of Environmantat Quality-Dicisio. o."Watcr Resources Revised 2-221-10 16