GW1-2021-02089_Well Construction - GW1_20210706

WELL CONSTRUCTION RECORD(4".,tW-I) For internal Use Only:
1.Well Contractor information:
Russell Taylor �,.. �� 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
Et. fit.
2187-A JUL Q ZfJ2�
it. 0 ft.
NC Well Contractor Certification Number t)1Z11 15,OUrER CASING for multi-owed Wells ORLINER of a livable}
c' Pr+oGD51C1f1
Heiden Brothers Well Drilling, It1„ff" n, c r%off
„ attOn FROM TU I DIAMETER THICKNESS MATERIAL
Company Name
INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: g`�Oa�{0-ao�o9 g• lOS4�tf FROM To DIAM1tETER TRICKYFsS MATERIAL
Usr all applicable well consintetion pernars(r.e.WC.Comity,State,Variance.etc.) R• ft. in. V/ti
3.Well Use(check well use): {,� fit. fit. in. p p (VE`
Water Supply Well: 17•SCREEN O
FROM TO DIAMETER, SLUT SIZE THICr-NESS MATERIAL
Agticuiturai Dlvlunicipal/Public ft. ft. in.'1
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
lndustrial/Cotnmercial Residential Water Supply(shared) is.GROU7 1
[Aquifer
ion FROM TO MATERIAL EMPLACEME.NTMETHOD&-.WOUNT
ater Supply Well: rt. 20 ft. «,18La pumped
oring Recovery ft. ft.
n Well:
fit. fit.
er Recharge 0Groundwater Remediation
er Storage and Recovery [�Salmi Barrier 19.SAND/GRAVEL PACK if applicable,
LJ ty FRUM TU MATERIAL F-MPLACEME\7a1ETHOD
Test OStormwater Drainage ft. fL
mental Technology [Subsidence Control ic. ft.
rmal(Closed Laop) Tracer 20.DRILLL"G LOG attach additional sheets if necessar)
rmal(HeatingtCooling Return) ; Other(explain under#21 Remark) ERUM To DESCRIPTION tcotor,hardness,soil/rock n e ram s;u,etc.)
0 rt, it• clay a sand
4•Date Well(s)Completed:A
®RAO—Ri—
Well 1:Dn ft. ft. granite
ASa.Well L. atocation:
� #r4*icio-jF��k rt. ft. I
Facility/___6wn���crNomc Facility ID#(if applicable) ft. fr.
83 t"Usm t+Ci Rd h It.
Physical Address,C and Zi tr. i it.
Jawoti cDujyrq 76M-5&-L7 0$ 21.REX4RKS
County Parcel Identification iNo.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelt field,one latliong is sufficient) 22.Certification:
,35° 61. *70 N 093° 09. 78A w
6.Is(are)the wells) Permanent or OTemporary Signature of Certified Well Contractor Datcr I
do�
By signing this fann,1 herebr certify that r trell(s)isas(were)conurrctrd in accordance
7.Is this a repair to an existing well: n yes or No ndttt 15A NCAC 02C.0100 or f M NCAC 02G.020D tt e11 Conslnrrtron Standards and that a
If this is a repair,fill out knonn well eonsirriction Information hexplain the nature of the copy of this record has been provided to rho well aumer.
repair under 03l rentarkr section or on the bark ofthis form.
23.Site diagram or additional vye11 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 I W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: K SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: tJ � (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple trells list all depths!)dierew(erample-3@ 200'andd2@100'1 construction to the fallowing:
10.Static water level below top of casing: I J�O (ft.) Division of Water Resources,Information Processing Unit,
I(water level is uhare easing,use"_" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:— ((n,) 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 h1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)� � Method of test: 24c.For Water Suooly& Injection Wells: In addition to sending the form to
t t �. the address(es) above, also submit one copy of this farm within 30 days of
13b•Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofErnironmemai Quality-Division of Wincr Resources Revised?22.2016