GW1-2022-05659_Well Construction - GW1_20220610

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only: I -
I,Well Contractor InfoiTnadon:
Russell Taylor 14.WATER ZONES i
Wcll Contractor Name FROM I TO I DESCRIMON
2i 87-A
ft. fL
NC Well Contractor Certification Number
15.OUTER C.ASMG Cfar multi-used wells ORLIlHER(If a table)
Hedden Brothers Well Drilling, Inc FROM To DIAMtETER rxtCiCNS HATEFUL
Company Name
ft. I fL I i In.
q 26.ID ER CASING ORTDBING(geothermal closed-too
2.Well Construction Permit : of�a� -0`11�a()-q- )► a o 9 FROMt I To DLlati<rER rRtch^lESS MtnTBRL1L
11
Litt all applicable bell consttttclion petatirs(h.a UIC Coun y.S/atg l ariarre,etc) I. n• I 8 IL
In. pYC
3.Well Use(check well use): $ ft. I it
I �jv in, I 0 ``1I'' r�� e
Water Supply Well: 17.SCREEr\ to O
FROM I TO DIAMtMR SLOTSIZE TMCIMESS MiATERLIL
Agricultural DMunicipal/Public ft. tr. in.
Geothera al(Henting/Cooling Supply) ,Residential Water Supply(single) ft. ft.
IndustriaVCommercial Residential Water Supply(shared) 18 GROUT
Irrigation FROM TO MATERUL EMiPLAC&IiE_NTMETHOD&AMiOL•,lT
Non-Water Supply Well: ft- I zo ft I cnransa,, ' pumped
Monitoring Recovery fL fL
njection Well:
A uifer Recharge ft. I fL
q a+Sc �GrorradwatcrRcmediation
Aquifer Storage and Recovery [�'�`�..Salini Barrier 19.SALnIGRAVEL PACK if applicable)
t--1 FROM I TO MUTERUL fSePLACEM1lE\TMiI7tiOD
Aquifer Test 0-StormwaterDminage II tL
Experimental Technology Subsidence Control tt. I ft_
l
Geothermal(Closed Loop) racer 20.DRILLLNG LOG st;ach additional sfieets if aecesaa
Geothermal(Heatin Coolin Return) Other(ex lain under i 21 Remarks) FROMI To I DfSCRIPTtON[color.hardaesa so}Uroek a rn arm etc.)
it, j p fL I clay S sand
4.Date Well(s)Completed: Well ID" i n. I ft. !�� I igranite
Sp �f'1 a..Well Location:
r ft. tt. I
l 3 Con, M 1 12i� fr. I fL
Facility/owncr\ame I Facility IDd(if applicable) it. I ft. I M
a89 �ell�i�� MDyn , ►Zd. L'0.sh►evs o'�871"7 I rt t=. i Physical Address,City,and Zip I ft. I ft. j JUN -
V CULL
i_" �t ! 21.RDIARKS
t.1 l nun1T!( -Jr8-97�� I D>ZV WELL a'Pre
County Parccl identification No.(PI\') 3O(3�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwetl field,one ladlong is sufcicnt) 13.Certification:
N 35 . 13 O NVI 1&25 i 7 oaa
6.Is(are)the weii(s) Permanent or Temporary Signature ofCcrtified Well Contractor Date
�} By signing this jonn.I herelro cert46j•that [ uell(s)uas(irerr)eoartructed in accordance
7.Is this a repair to an existing well: n Yes or I\=a melt 15d NCAC 03C.0100 or lS.i NCAC 0?C.0100 If e11 Construction Smndards and that a
If this is a repair fill out known[vrll construction injor tuaian -r"iain the raturr.ofthe copy of this retard has been prorlded to the it-ell ouaer.
mapah-under 921 remarks section or an the back ojthrsfom+_
23.Site diagram or additional tve]I 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 I OW-1 is needed. indicate TOTAL N NIBER of wells consuucdon details. You may also attach additional pages if necessary.
drilled. —A- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'DOO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple arils list all depths il'diffetrtrt teram dr-3@200'and 1Q/00'1 construction to the followine:
10.Static water level below top of casing: '600 (ft.) Division of Water Resources,Information Processing Unit;
Ifivater/avel is above easing.use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
�� above, also submit one copy of this form Rithin 30 days of completion of well
12.Well construction method: _G 1 �j C 1 construction to the followin=_:
(ix.auger,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
13a.Yield(gpm) 0 Method of test• 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form mithin 30 days of
13b.Disinfection type: Amount: �0 l completion of well construction to the county health department of the county
,� tvherc constructed.
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Font G11'-I North Carolina Depann ens of E.-ironm-mm!Q..clity-Diaor.of P:atcr esou:ccs Rc%ised 2-22-2016
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