GW1-2021-00224_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD (GW-1) For Tntemal Use Only: �'
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A ir' 73 rL
it. Apqf7 tt.
NC Well Contractor Certification Number
15.OUT=CASING for multi-cased wells OR LINER able
Hedden Brothers Well Drilling, Inc -MA To DiAMET'ER nttctcvEss MATERIAL
Company Name n R ft. in.
2.Well construction Permit 9:Jyot1�0115109-�q� �'28D 16'livNE FROb1 —1 TTO o G OR TDBING eothmrmal cto 1DtA.11ETER 7HiCf0=CtGYESS iF1ATBRLAL
Gist al1 appitcable artl construction peewits#.a LUC,County.State,Parlance,etc.) R. 1 ,1_ fL In.
PVC
3.Well Use(check well use): a fL '7" fa in.
Water Supply Well: 17,SCREEN
Agriculture] FROM TO DtAb1ETER St.OTS,ZE THICKNESS �iA L
gn [3Municipai/Pubfic ft, ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft• ft.
hidustrial/Commercial Residential Water Supply(shared)
IS.GROUT
Irrigation FROM TO \rATETitAL &IIPLACLNIE1?.IiETH D S A.IIO TT
Non-Water Supply Well: rL 20 fL eem,,+e, .,, pumped
Monitoring Recovery ft. [L
injection Well.
Aquifer Recharge E)GroundwatcrRcmediation fr. I fL
Aquifer Storage and RecoveryI9.E&t IGRAVEL.PACK if a licable
Salinity Barrier FROM TO MATERIAL E�TPLACEaiMM METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control fr. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necesso
Geothermal(HeatinglCooling Return) 0 Other(explain under#21 Remarks) —FRoat To DESCRIPTION eoJar.hardnesr soiUroet rain she etal
tt' I LP
iL clay 8 sand
4.Date Well(s)Completed:��1'r_.�ha , WellIDS fL ft. granite
Sa.Well Location: ft._>LYc tt.
Kln
Facility/OwncrName (, Facility
IDpa(if applicable) fL ft. `
VDEC I
P f" s WAO ee O!89 � ft. [t.
=1CAAdd ,sty,and Zip ft. I tt.
7553-II-j ice?8 S1.RENL4RK3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
,360 D9.410 N 0930 lD. 29.3 w
6.Is(are)the wells) Permanent or Temporary Signature of Certified Weil Contractor Date
by signing this jorn,.!herrbr certify Thar , url!(s1 teas(Were)eon Oneted in accordance
7.1s this a repair to nn existing well: []Yes or No With 15d NCAC 0IC.0l00 or ISd NCAC OIC.0200!Nell Construction Srandards and that a
lfthis is a rrpair,fill out knorm rvrll eonstructlon information ,eIrsplain the natter ojthr copy q(rhis record has beets provided to the aril owner.
repair under 921 remarks section or on the back oj1hLefdrn1.
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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ISUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5a5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For maidplr wells list all depths Irdyfetrnl k atnplr-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing; 110 (ft.) Division of Water Resources,Information Processing Unit,
Iftvater level is above casing.use {^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:� (in) 24b.For Iuiection Wells. 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 well
12.Well coastruetioTi method: construction to the following:
(Le.auger,rotary,cable,direct push,etc)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q� ^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) _ ,Method of test: 24c.For Rater Suoo v S Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form Itithin 30 days of
13b.Disinfection type: Al Amount: Q1 completion of well construction to the county health department of the county
,-here constructed.
I
Fonn OW-1 North Carolina Department of Emironmantal Quality-Division of Water Resource Revised 3•21•3016