GW1-2022-01888_Well Construction - GW1_20220210

Pr'intForm''
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A
a. e.
NC Well Contractor Certification Number 15.OUTER CASING foi mull cased wells ORLDVER(if a 1[cable
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name I&INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: U�3O5a I— 1 FROM TO DIAMETER I THICKNESS MATERIAL
List all appilcable well construction permits(.e.WC,Catmty,State,Variance,etc.) ft. 8 ft. in. e
3.Well Use(check well use): a It. 30 fL In. I S g SEW
Water Supply Well: 17.SCREEN ��:.
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) MiResidential Water Supply(single) R. tt. in.
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUT
IPri ation FROM I TO MATERIAL EMPLACEMENT METHOD&A:NIOUNT
Non-Water Supply Wcll: 0 ft• 20 ft* —,a..�,.. pumped
Monitoring Recovery
Injection Well:
Aquifer Recharge E)Groundwater Remcdiation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. It.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) ' Other(explain under#21 Remarks) 01 FROM To DESCRIPTION tcoloG nardaes:,rolurn k type, ram size,ere.)
day&sand
4.Date Well(s)Completed: Well ID# 010ft' e L granite
Sa.Well Location: ft. ft.
'
Facility/Oa tcrNa ft.
c Facility
n ft. _
a o�
Physical Address,City,and Zip ft. ft. 2021)
o? 21.REMARKS
County Parccl Identification No.(PiN) rr ,✓-A .,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwwctll ficld,one Iat/long is sufficient) q 22.Certification: C� n
. J 0�N 10O9 t 1,2. g W &,�'
/ '7oA'a
6.1s(are)the wells) Permanent or OTemporary Signature of Ccnified Well Contractor Da
By signing this form,1 herebv certify that r well(s)was(were)cons cled in accordance
7.Is this a repair to an existing well: OYes or No udth 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Constuction Standards and that a
/fthis is a repair,fill out known well consintction information hexplain the native of the copy of this record has been provided to the sell owner.
repair tinder#21 remarks section or air the back of dds form.
23.Site diagram or additional tve11 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 1 GW-1 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: �t�V (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifati Brent(example-3Q200'aan^nd 2Q100') construction to the following:
11 10.Static water level below top of casing: Of (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing,use-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection 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 construction method: t�
.t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Vnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 16 Method of test: boo 24c. For Water Suuoh'&Inlection Wells: In addition to sending the form to
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 GW-I North Carolina Dcpanment of Eniironmental Quality-Division of Water Resources Revised 2-22-2016