GW1-2022-03248_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD (QW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
2187-A ft. ft
fr. fr.
-VC Well Contactor Certification Number
Hedden Brothers Well Drilling, Inc FRO 17TEItC a2NG fort1 DIAMETERells O>HI ICMS a u
Company Name ft' ft. I in.
TNER CASING OR TUBING eothermal doseddoo
I.Well Construction Permit I To I DtA IP, R Tarcl vEss iNATER2AL
Eut all applicable wsl►consmrctton permits(.a UfC,Coluio,State,Irarianre,etc.) iT• i W rL /,�W !n. 1-8-8
vQ 5,MFL
3.Well Use(check well use): fr. it. ;n,
Water Supply Well: 17.SCREErN
Agricultural Munici aMblic FRONT To DTAIt1ECER SLOTSIZE THICKNESS MATERIAL
p ft. ft. in.
Geothermal(Henting/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
IndusttiallCommercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO JTATERGIL E11PCAcEaiE\T,iETHOD S AVIOLrr\T
Non0 'ton' Supply Well: 0 rt• 20 � I r I pumped
Motutoring oRvcovery R R. I
injection Neil:
Aquifer Recharge 0Groundwatcr Rcmediation fr.
Aquifer Storage and Recovery 19.o S�AiiND/GRAVEL PACK if applicable)
I To I SLkTERIAI. E\IPLACET+TE\T31MOD
Aquifer-Test Et-StormwaterDrainage te. I tc
Experimental Technology Subsidence Control tr. I ft.
Geothermal(Closed Loop) Tracer 20.DRII LL?GLOG attach additional sheets if aeeessa )
Geothermal(Heatin Cooling Return) MOther(explain under',21 Remarks) FROM I To I DESCRIPTION(color.hardness.soi0roek typpgrain star,etal
R' I I day S sand
4.Date Well(s)Completed: Well ID# I it o ft.
granite
Sa.Well Location:
(,.o�Iedivft�anagelrt�r,liGl.0 rr. s. I
Paeil'ty/Owner Name U Facility iD4(if appiicablelfti {t,ieX5 E4t OASh;ek5 a8717 rt. ft. I
Physical Address,City,and Zip R. I ft.
gUSON �N,} 21.REHARKS
County Parcel Identification\a.(PIN) 1A D&IWELL,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwall field.one Iat/lons is sufficient) 22.Certification:
35° ola. sap iv 083 ° a�5. 88,1+ w140aq
6.Ware)the well(sApermanent or 0,Tempomry Signature ofCvttified Well Contra or Date/
By signing this form•1 herebr eerlyy that r rrellts;+rag lwz•re)constructed in awardaner
7.is this a repair to an existing well: n Yes or No with 15A NCAC 02C.0100 or;SA YCAC 02C.0700 Mell Construrtion Standards and that a
Ythis is a repair,fill out knotty nr11 construction Information derplain the nature.orthe ropy gfthis record has been prorided to the well owner.
repair under 921 retnark7 session or on the back of dtisfornt.
?i.Site diagram or additional ne11 details:
8.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 GW-1 is needed. Indicate TOTAL NUMBER of«•ells construction details. You mayalso anach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: .SOV (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple oohs list all depths ifdierent(i rainp/e-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: D (ft.) Division of Water Resources,Information Processing Unit;
Iflvals)./o el is above casing,use 1617:`tail Senice Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For lniection Wells: In`addition to sending the form m the address in 24a
n� (1 r at-�
12.Well construction method: above, also submit one copy of this form Rithin 30 days of completion of well
_S t fed
au �— construction to the follotvtiag:
(Le gee,rotary,Able,iliac(push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) Method of test 14c.For Water Suooh•&Iniection Wells: In addition to sending rho form to
tt�� II the address(es) above, also submit one copy of this form mithin 30 days of
13b.Disinfection type: : 14_ Amount: 1 d QA1 completion of well construction to the county health department of the county
«byre constructed.
Form G%V-I North Carolina Department of En+ironmcnt.l Q"-liry-Division of Wamr Resources Revised 2-2-1-1016