GW1-2022-06706_Well Construction - GW1_20220712

WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATERZONES
1Vcll Contractor Name FROM To I DESMUPTION
2187-A i&
ft.-
I00 tt:
°-ICJ ft. 0 fc.
NC Wcll Contraetar Cenificaaon Number 25,OUTBR CASMG for mull-casad wells ORLMER(If applicable)
Hedden Brothers Well Drilling, Ir1G FROM TO I DIAMETER I TMUCfEss tKATERI"
ft. I ft- I In.
Company Name
qq n �l m p p i L1'NERCASING ORTUBING eothermalCloseddoo
2.Well Construction Permit-,,• Ol()�S�-of 1,37-1— �1 —11(0 0 FRoaf To DLM%tErm I TMCAREss bfArERtAL
r&r all applicable ttull ronstmenon perntfts(t.a.V7C,Comity.State,Yariance,etc.) R. I fL / In. ()v
3.Well Use(check well use): ft' I % I w in. I . 18$ f T� •
Water Supply Well: 17.SCREE:'
FROM I TO DIA.IIETER SLOTSIZE THICIG\ESS MATERLIL
Agricultural []Municipal/Public ft. ft. I in.
Geothermal(Heating/Cooling Supply) ®Residentia]Water Supply(single) ft. ft. I I in. I
industriaUCotamereial Residential Water Supply(shared) 18.GROUT
Irrigation FROM I TO I MATERL L. EbIPL4CEDIENTSIETHODL-.L\tOL1-r
Non--Water Supply Well: � fL 20 it. I I pumped
Monitoring Recovery ft. I ft.
I
jection Weii:
ft. I IL
I
Aquifer Recharge 0Gtoundwatcr Remediation
I9.SAND/GRAVEL PACK ita oGeable)
Aquifer Storage and Recovery �Saliniry Barrier FROM TU SEATERLtL VNIPLACEME.W METHOD
Aquifer Test M-StottnwaterDrainage tt. I fL
Experimental Technology Subsidence Control. fr. tL i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG atfacb additional sheets ifneeesse )
Geotherma](HeatinaCoolinelletum) •Other(ex lain under=Z1Remarks) tRo�t rp I MCRIPTION1color.hardn�.salttrocl e. tnAMetw
Ct it. I fL i `clay S sand
4.Datc Well(s)Completed: (O ,R !Nell IDr I tr. I 00
So.Well Location-.
ft. (
N .um 1 IP son I fr. I R. i
Facility/Ter\amc Facility IDS(if applicable) fr. i ft. I ''
+.:
19 4 C-MJdtn eroeK.Qd llou o 0?aWQ,� `° tt• c � Ti�;�
Physical Address,City.and Zip i ft' lr Q+ ,,Atititr'lO2OCESCiMIGUI
rJ5"'5,Q-8ao0 1 31.R,IIARKS
Ji ro C)�NTy
County Parcel Identification No.(PIS) I
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(if well field,one fatilong is sufficient) 22.Certification:
36® Ile-524 rt D83� I.Q. Ia5 w
zfe2z.11A
6.ls(are)the wells) Permanent or Temporary Signature ofCeri fled NVcll Connector Date
�+ By signing ribs forur,1 hereby certify that t well($)was(were)corurrueted is accordance
7.Is this a repair to an existing well: FlYes ortcNo tsidi IS,.NCB C 03C.0100 or t f4,VC.4C 0?C.oZ00 ff ell Cotrstruction 9andatds and that a
lflhir fs a repair,fdlout knout well construction information lecplain thr.ature..Wthe copy grrhir record has beer provided to the well comer.
mpair under AU remarkrsection or an die barkofthis•fama 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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Soo (fG) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(hrample-3(g200'and 2Q100') construction to the following:
p of : PT'i/�+
Division at water 10.Static water level below to (fr.casing: ) Resources,Information Processing Unit,
lfivater level is above easing,use'=" 1617:`Sail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For lniection Wells> In addition to sending the form to the address in 34a
L- above, also submit one copy of this fort nithin 30 days of completion of wail
12.Well construction method: L�,1 /r.{-� construction to the following:
(La 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
I3a.Yield(gpm) Method of test: 24c.For Rater Sunniv g Injection Neils: In addition to sending the form to
the address(es) above- also submit one copy of this form within 30 days of
13b.Disinfection type; Y3 amount l d completion of well construction to the county health department of the county
` where constructed.
v
form GNV-1 Nonh Carolina Depart^.ent of Eaci-anr.,an;al Q•.:ality-Di ision,of WaLar Rcsou ms Rcvised 2?'-101 b