GW1-2022-03317_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
Russell Taylor 14.WATER ZONES
Well Contractor Name FRONT TO I DESCRIPTION
2187-A r7 It- ft.
O ft. fL
YC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells ORLMER(lf a cable)
Hedden Brothers Well Drilling, Inc FROM TO T DIAMETER THICIL-fus MATERIAL
ft. fL in.
Company Nance
16.P11VER CASING OR Tt1BING eothermal sed-tonril
2.Well Construction Permit FROM To DTANIETER I Tmcilms MATERIAL
r&t all applicable trell cortsm(etion perm(rs(i.r-WC.County,State,Variance,etc) D R• SIP ft. In. ve
ko
3.WWI Use(check well use): ft• IL in. 8 G eel
Water Supply Well: 17.SCREEN C1
FRONT TO D1,01MM SLOTSIZE THICICUNESS I MATERIAL
Agricultural C)Municipal/Public te. tt. in
Geothermal(Henting/Cooling Supply) Residential Water Supply(single) ft. ft. to.
IndustriaUCommercial 0,11esidential Water Supply(shared) is.GROUT
Irrigation FROM I MATERIAL Ea1PLACEaIE\T3lETHao&*A110Li\T
Non-Water Supply Well: 0 r, zo rL pumped
Monitoring 13Recovery ft ft. I Injection Welh
ft. fL
Aquifer Recharge DGroundwater Rcmediation
I9.SADiD/GRAVEL PACK if a Iicable)
Aquifer Storage and Recovery Salinity Barrier PRO.
To SfATERLkL E.�fPLACEATE.\TMETHOD
Aquifer Test 0stormwaterDrainage ft. 1 tc
Experimental Technology D-Subsidence Control fr. I ft I
Geothermal(Closed Loop) Tracer 20.DRILLL\G LOG attach additional sheets if necessary)
Geothermal(Head Coolin Return) Other(e lain under�21 Remarks) FxA To I DESCRIPTION(color,hardnesr.sollfroek a in sires eta)
D• I r78 fL clay 3 sand
4.Date Well(s)Completed: Well ID' 1'78 fr. '760)
fL I gnleite
Sa.Well Location: ft• ft.
fr. ft. I
Facility/OwnerName � Facility ID9(if applicable) ft. i ft. i
Ave rt. I rr. i e ._.�,��'sfv a8'7
Ph sical Address,Cit. Zip _r T, I rt.
IA Aih Co 21.Rl-NURK.S
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is Sufficient) 22.Certification:
35° 49.LOS V D830 163 W
zEV/J'-11-1ff I
6.is(are)the well(s) Permanent or 01remporary Signature of Certified Well Contractor Dat
By signing this form,l hereby certify that t twiftJ ryas(nerd eaartrueted in accordance
7.Is this a repair to an existing well: nYes or No aitlt JSA NCAC 02C.0J00 or(F,4,VCAC 02C.0200 Mell Construction Standards and that o
#'this it a repair,fill out known well construction fnfonnatinn taespfain the noitrre..ofdrc copy gfthis record has been provided to the well owner.
repair under 921 retnankrsecthn,or oil the back ofrhisfornt. 23.Site diagram or additional well 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�W-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /On (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nrlls list all depths ifdderent(Prample-3@200'artd 2@1001 construction to the following:
10.Static water level below top of casing: .3QQ (ft-) Division of Water Resources,Information Processing Unit,
Jfwaterlavel is above casing use"_" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (rn•) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
L above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_���h, ? 1. construction to the following:
(i.e.augar,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
i
13a.Yield(gpm) 3 iMethod of test:__ 24c.For Rater Suooly &Iniection Wells; In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ Amount: �d t�e completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Enviranmcmal Quality-Division.o;'t:•atcr Rcso;{tcu Revised 2-2_'-2016