GW1-2021-02104_Well Construction - GW1_20210706

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ALL CONS— RUCTION RECORD (GW-1) For Intema!Use Only:
I.Well Contractor Information: .,
t
Russel!Taylor '��. _ �s 14.IitATERZONEs
Well Contractor Name FROM TO DESCRIPTION
2187-A ,UL Q -0 500 it. J606 ft.
NC Well Contractor Certification Number o�eesStri Vt�11 r ft. &9D IL
1S.OUTER CASING for multi-cased wells OR LINER(If applicable)
Hedden Brothers Well DrillinglylWdrr+atlan r ;
���?r r;1+Qr1 FROM TO DIAMETER TH3CKYESS MATERIAL
— ft. 0• in.
Company Name
4916.INNER CASING OR TUBING(geothermal elosed-Ioo
2.Well Construction Permit;: "/98'0?0 - 9~103 iV FROM TO DIANIETER 1MCKNESS 1fATERIAL
List all applicable sell construction permits(i.e.UIC,Couuo,State,ilariance,etc.) 0 R. 3$ iL j In, P yr,
3.Well Use(check well use): .0 ft. *O fl- In. Sg STEEL
Water Supply Wep: 17.SCREEN
A Cultural FROM TO DIAMETER SLOTSlZE THICKNESS MATERIAL
nMunicipal/Public ft. it. in
Geothermal(14enting/Cooling Supply) SUResidential Water Supply(single) ft. ft. in.
IndustrialtCommerciai OResidential Water Supply(shared) 18 GROUT
irri ation FROM f TO MATERIAL EMPLAr.E;IIE1TltETHODS 1\IOtfI�T
Non-Water Supply%Veil: ft, zD fL pumped
i' Monitoring Recovery fr.
§Aquifer
jection Well:
A uifcrRccha a fL ft.
q t'g �Groundwatcr Rcmediation
Storage and Recovery 19.SANDIGRAVEL PACK if a licabie
$ ry SaliriityBarricr FRObf TO MATEttLIL EMPLACEMENTMHTHOD
Aquifer Test 0Stormwater Drainage R. Ir.
Experimental Technology DSubsidence Control ft. ft-
w Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Coolin Return) ' Other(explain under#21 Remarks) -FROM TO I DESCRIPTION itater.hardness,soiltrack trae.grain size,etc.)
0 is' I D fL r day&sand
4.Date Well(s)Completed: + ..3 040-'1 Well IDrr 30 ft• $OD ft. granite
Sa.Well Location: rt. ft.
.J145-til, Ala-o►is ft. ft.
Facility/OCwner Namc ( ,,���/! Facility IDS(if applicable) ft. fL
5� oY 1`lo�han Kam• bllJ60 0-G��82�
Physical Address,
/City,and Zip ft. ft.
'7654-31-68 74 21.BRIMS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(ifwoll ficid,one Iaviong is sufficient) 22.Certification:
J-2 1 A• 9IP 7 N D '3 >0 .39!Z Wi foCLA
ars m?as�
6.Is(are)the txell(s) permanent or OTemporary Signature of Certified Weli Contractor Date
�-I By signing,iris form t fi,1 hemkr cer �thataysVll(s)gas(xrt c)coacirrtcted in accordance
7.is this a repair to an existing well• e_.t Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200,fell Construction Standards and that a
If tiffs is a repair,fill out knotssr well construction/nfornrniionP&Iexpfain the nature o(the copy ofthis record has been provided to the it-ell aumer.
repair under'?[rrmarks sewicut a•art the back ofthisfenn.
23.Site diagram or additional well details:
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Weil site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled. 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ?!DO (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltittle wells list all depths ifdifferew f wornph 3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: lib (ft.) Division of Water Resources,Information Processing Unit,
tfwater level is above casing.use"-" 1617 Mail 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
above,also submit one copy of this farm within 30 days of completion of well
12.Well constructiori method: 01 }� jta
(i.e.auger,rot P .r- construction to the following:
g rotary,cable,direct ash,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 NVater Supply&Infection 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:_ a 1 Amount: 4 d 0.0 completion of well construction to the county health department of the county
where constructed.
Fonn 0W-1 North Carolina Department of Environmemal Qw:lity-Division of\+later Resources Revised 2-22-2016
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