GW1-2022-01887_Well Construction - GW1_20220210

OHni Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only
1.Well Contractor Information:
Russell Taylor 14.R'ATERZONES
Well Contractor Name FROAr TO DESCRIPTION
2187-A ft.
ft. ft.
IC Well Contractor Certification Number 1S.OUTER CASING for multi•eaaed wells)ORLINER 11f a able)
Hedden Brothers Well Drilling, Inc FRO.i To DIAMETER THrctcNEss KATEtuAt,
Company Name ft. I fL in.
g Q A� 16.INNER CASING OR TUBING eothermal closed-1
2.Well Construction Permit#:d=-I r Me I�'7"9K�f FROM To DtA.�IErER THICl,�tEss I MATMAL
Ust all applicable rill consmtctfon pernihs ri.a UIC,County.State,Variance,etc.) 0 R• I o?`7 ILID in.
3.Well Use(check well use): anfr- I to fr' in- I . I TE EL '
Water Supply Well: 17.SCRELN
FROM TO DWIETER SLOTSIZE I THICKNESS MATERiAL
Agricultural [3Mimicipal/Public ft. ft. in.
Geothermal(14enting/Cooling Supply) §Residential Water Supply(single) fr. ft, ion
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO I MATERIAL T ElrPLACEdIE.\T 3lETHOD S A.IiOLIT
Non-Water Supply Weil: ft. 20 ft. ca aGoy:ae pumped
Monitoring ORecovery ft. I R.
I t.
Injection Well: ft. I f
Aquifer Rcchatgc [)Groundwater Rcmediadon
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery D-Salinity Barrier FROM Tv NIATERLU EaIPLACEIIF-S MEfHOD
Aquifer Test MStormwater Drainage it. I fL
Experimental Technology Subsidence Control fr. I ft.
Geothermal(Closed Loop) Tracer 20.1)RMUL.ING LOG attach additional sheets if necessary)
Geothermal(Hearin Cooling Return) Other(ex lain under#21 Remark) FROaI To I DESCRIPTION'tcolor.lnrdness.salitrock a rain Am eta)
' l fi clay&sand
4.Date Well(s)Completed: / / djt9o? Well ID# I granite
Sa Veil Location. ft. ft.
�'MGIn !'Y�W 0.KI I fc. ft.
Facility/OwncrName Facility iD-(if applicable) ft' ft.
J et *14 C,le,>Sl,t, SGri 87 I r7 `` f`.
Physical Address.City,and Zip o�T ft. i ft.
t CWNrl 7,654- Wip-9&3co 21.REhLARKS
County Parcel identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one ladlone is suf icicnt) 22.Certification:
350 1D.808 N 083 09•to8(o W za'Qe�
I
6.is(are)the well(s) Permanent or Temporary Signature of Certified%veil Contractor Dare
By signing this join,.1 hereby certify that , uzl!(s)+vas(I.,)constructed in accordance
1.1s this a repair to an existing well: [3 Yes or No +sith!SA NCAC 02C.0100 or ISA NCAC 02C.0200(fell Construction Standards and that a
!#'this it a repair,fill oar knonn,vrll construction information u?explain the nature of the cop)'grthis record has been provided to the well m mer.
repair under 4IJ re narksseciion or an the back ofthisform. 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 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60 (it.) 24a. For All Wells: Submit this form ntithin 30 days of completion of well
For multiple t,vlis list all depths ifdierent(rratnplr-3Q2000'and 2Q100') construction to the following-
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit
if water level is above easing,use"=" 1617!Sail Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: (in.) 24b.For Inieetion Wells: In addition to sending the form to the address in 24a
{L above, also submit one copy of this form n•ithin 30 days of completion of well
12.Well construction method: h, n construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) dIethod of test: 24c.For Water Sunoh•8 Inieetion Neils: hi addition to sending the form to
S i the address(es) above, also!submit one copy of this form within 30 days of
13b.Disinfection type: i'T amount: d completion of well construction to the county health department of the county
t+.`%ere consaveted.
Form GW-i North Carolina Deoanm¢nt of Enimnmemal Qcrlicy-Di sia.:o:%t'_c:r Resources Revised 2-2-1-2016