GW1-2022-05657_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD (_GW-1) 777m
al Use Only: I —
1.Well Contractor information: I
Russell Taylor 14.WATER ZONES i e.
%Veil CotimictorNo= FROM TO I DESCRIPTION
2187-A I ft. ft
' ft. ft.
YC Well ColtaacW Certification Number 15.OUTER CASING for multi-cued wells OB LINER ftf a eablel
Hedden Brothers Well Drilling, Inc FROM TO DIAMf:TER THICKVF.ss MATERIAL
Company Name !
ft. I fL In.
I6.IDTNER CASING OR TUBING eothermal dosed-loo
1.Well Construction Permit#: u�0•71-4J IM—9—11_3O2 FRDM I TO atAusrER TEtCl%..MsI MATERIAL
fdrl all applicable null Construction perntRs(t.a 111C,Cowtry,Store.Yatiance,etc.) I. R• I of SL („ in. Pv C
3.Well Use(check well use): a ft. I a,,f, is. W in. ( -18 Y L ,
IN"IMonitaring
ater Supply Well: 17.SCREEN
FROM I TO DIM ETER SLOTSIZE THICI0IESS 1ATERIAL
Agricultural C)MtuticipaYPublic ft. ft. to.
eothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft. ! ta.
IndustriaYCommercial Residential Water Supply(shared) ill.GROUT I
Irrigation FROM TO MATERIAL I EdIPLACEDILIT.IIMOD S A 10L1T
on-Water Supply Well: � ft. I 20 it. I �.arr m I pumped
MRccovery fL I ft.
njection Well:
ft. It.
Aquifer Recharge 0Crroundvvatcr Rcmediation
I9.SAND/GRAVEL PACK if a Ileable
Aquifer Storage and Recovery M-Salinity Barrier FROM I TO I bUTERIAL L%tPLAMIF-\T>IETHOD
AquiforTest Mstormwater DrainageIt.
Experimental Technology OSubsidence Control i ir. I Is.
Geothermal(Closed Loop) 0-Tracer 20.DRII .NG LOG attach'additional sheets if necessary)
Geothermal(HeatinglCooling Return) MOther(explain under#21 Remarks) FROM I TO I DESCRIPTION[color.hardatm solurork In sits eta)
40 % 1 is I clay a sand
4.Date Well(s)Completed:4k•?o2R Well ID# I . f� !
i14 ft I i jg:ani[e
Sa.Well Location: ft. ft.
g Coru M I Ie- ft.
Facility//OOwwncrNoma Facility ID9 Of applicable)
//lA ft. I ,m
��/ ' ���►,l>..� Min Rd l t a. hle+-.5 a 6713 Cc I Ir. I tnu a
Physical Address.City.and Zip f' �+�
JflQKSon1 /wwr� /J�Jr.J�(-58-9%7 ' 21.REMARKS
County Parcel Identification No.(PIN) Q. UNA
PreG-
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: 1f1 �h 0MOG
(if well field,one lat/long is sufticicni) 22.Certification:
350 61 933 N 0830
09. 7&I ff G a� ao�z
6.Is(are)the well(s) Permanent or 0-Temporar} Signature ofCenificd Well Contractor Date
By signing this fonu.1 herrbr cenifv that t tml!(s)nos(nerr)eoartrueted In aa:ordancr
7.Is this a repair to an existing well: OYes or No pith 15A 1vCAC 02C.0100 or IS.4,VCAC 02C.0100 Mell Construction Mandards and that a
lfthis fs a repair•fill our knowt writ construction information ecplain the nourre..of the copy ofthis record has been provided to the urll onver.
repair under i 21 rernarlssection or on the back ofthisfornt. 23.Site diagram or additional well details:
S.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 OW-1 is needed. Indicate TOTAL NUMBER of.veils construcron details. You may also attach additional pages if accessary.
drilled: /-fh SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: CDt/V (ft.) 24a. For All Neils: Submit this form within 30 days of completion of well
For multiple arils list all depths lfdilferml ticratnple-3@200--'and 2Q/00') construction to the following:
`` me�
10.Static water level below top of casing: (00 (ft.) Division of M ater Resources,Information Processing Unit,
(fivater level is above casing,use'=" 1617.Grail Service Center,Raleigh,'14C 17699-I617
11.Borehole diameter: (irs.) 34b. For Iniection Welts:' In addition to sending the form to the address in 24a
L above, also submit one copy of this form nithin 30 days of completion of well
12.Well construction method: J construction to the following:
(Le,auger,rotary,cable,direct posh,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) C J X-Iethod of test: 24c. For Water Suonh•k Iniection Wells: in addition to sending the form to
r
the address(es) above, also submit one copy of this form G%rithin 30 days of
i3b.Disinfection type: amount � e completion of well construction to the county health department of the county
,� where canssueted. �
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Form OGV-i North Carolina Depar mnt of e-vironm.2=1 Q: lin--Di,isim:oft':=_ecr Rc50a:cC9 Revised 2-2-1•2016
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