GW1-2022-05630_Well Construction - GW1_20220610

Prin Form
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor information:
Russell Taylor 14.WATER ZQAW
Weil Contractor Name FROM TO I DtSCIUMON
2187-A ft. 'L 17_
NC Well Contractor Certification Number rr. /00 R•
Hedden Brothers Well Drilling, Inc MUM
VIERCTO fortauDl AMETERells OTHII KMS ll�MA
TERIAL
Company Name /� ft. fL In.
O I I�Oa�o2-P 16.4YNER CASING OR TUBING eathermal closed-loo
2.Well Construction Permit#: >:& To DttalErER THnctWEcs braTBRIAL
List all applicable tall mtuttuetlon pernuts(.a U1C,County,States Variance,eta) R I O Tti 1n. �^
3.Well Use(check well use): 0 It. ( a It.
to in. JAR ,-rc
Water Supply Well: 17.SCREEN C>O
Agricultural FRObt TO ➢iMIETER SLOT SIZE THICKNESS MATERIAL
�Municipa!/PubGc ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft, ft. in.
Indus➢iallCommercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO JtaTERL1L EdtPLt10EME\7A[ETHODS I�fOL1T
Non-Water Supply Well: � ft• 20 tt• I maaens,a , pumped
Monitoring Recovery ft. ft
Injection Well:
Aquifer Rcchargc E)GroundwatcrRcmediation fL I fL
Aquifer Storage and Recovc 19.SAND/GRAVEL PACK if a ncable)
ry Salinity Barrier FROM To MATPE tLAL E.MPWCEM1IE.\TMETHOD
Aquifer Test [3Stormwater Drainage tt. ft.
Experimental Technology Subsidence Control tt. I rt
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coolin Retu f7,Other(explain under r21 Remark) }BoatI TO I DESCRIPTION leolor.hardness.sonlrork L grain size eta) !
R I d�a rL i clay a sand
4.Date Well(s)Completed: 0 Well IDn ( /1�,� fr. I µ,Op tL I granite
Sa.Well Location: ft. fit
LETS NC tt. I ft. I
Facility/OwncrName FaeilirylD�(ifapplieable) ft. � ft. I ( v � -
i A 8 rl
ft. ft. I UN 1 0 2
Physical Address,City,and Zip 5 4 IOo r/ ft, I ft.
L rITa�t I
1R
i'MM /J11.Ot a OOA ( .f!)'lit 3 21.RE;4IARKSIPA
County Parcel Identification No.(PIN)
I
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
-35' 04, 71 D t i _ 0830 /a. &83 W
5Ao .Vwq
6.Is(are)the wells) Permanent or 3Temporary Signature of Certified well Contractor Date
"tri'� By signing this farm•1 hereby certify that t xellts;eras l»ere)constructed in accordance
7.Is this a repair to an existing well: nYes orPi-expIainihenaturrofthe
NO t+ith 154 NCAC 02C.0100 or lS.t,VCAC OZC.OZ00 Well Construction Standards and that a
if this it a repair,fill out 4notm well cousinrerion information copy gfrhis record has beet:provided ro the well ouster.
repair under 921 r emantz seuion or on the back of this form.
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 1 OW-1 is needed. Indicate TOTAL NUNIBER of wells construction details. You may also attach additional pages if necessary.
drilled: �,j,/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple prlls list all depths ifdifferent leramplr-3Q200'an//d��2Q/009 construction to the following:'
10.Static water level below top of casing: R U (ft.) Division of plater Resources,Information Processing Unit,
/fivaterlevel isahauncosing,use"_" 1617.Nlaii Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For lniection 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: Lh, construction to the following:y
(i e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: p� ^ I636 Mail Service Center,Raleigh.NC 2 7699-1 63 6
13a-Yield(gpm) O 3-lethod of rest-. 24c.For Water Suooh'&Iniection«tells: In addition to sending the fom to
the addresses) above. also 'submit one copy of this form vtithin 30 days of
13b.Disinfection type: amount: ( 0 completion of well construction to the county health department of the county
where constructed.
Form GW-1 ?North Carolina Department of E,:eiranmcneal Quality-Division o;.%VBtcr R.s'ourcc; Rc%ised:'1-2016