GW1-2022-06708_Well Construction - GW1_20220712

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
1Vc11 Contractor Name
FRON I TO DESCRIMON
2187-A ft. I fG 1 816"
8% It. 880 ". '
SIC Well Contractor Certification Number IS,OU=,gASMG for mull-4=ed welts OBLIlYER fff a ee3lte)
Hedden Brothers Well Drilling, inc FROJI To DIAMETER THICKNESS MATERIAL
fL fG
Company Name I
I�a n n.nn G t-� 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permitir: C 0'-10--e�bc-•r Q- i-J Ile"/3 FROM To nta.�t=R TxiCIGVFss MATERIAL
Litt all applicable tnell coturniction pernifts(.a.WC,Coracry,Stare,Parlance,etc) R. l Cp41t. & In.to /-VC,
3.Well Use(check well use): ft. I (p tt- I I r 8 a S 5f L
Water Supply Well: PRM SCREEN II TO DWIETER I SLOTSIZE THICKNESSI MATERIAL
Agricultural DMurticipal/Pubfic ft tt. A in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared)
i&.GROUTIrrigation if FROM I TO I MATERIAL I ENIPLAC&\ILNT',%fETHODS.LNIOLTT
Non-Water Supply Well: 0 ft- I 20 rt. I I pumped
Monitoring ©iRecovery R. It. 1
Injection Well: I ft. I tL `
AquifcrRcchargc Groundwater Rcmediztion f 19.SAND/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery Salinity Barrier FROM I To I MATERUL L%IPLACE%1F-N r>tETHOD
Aquifer Test 0-StormwaterDrainage ir. j tc I
i
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DR11,LlINGLOG attach additional sheets if n=essaryl
lGeothermal(Heatln Cool'meRecum) Other(explain under r21Remarks) FROM I To I DFSCRIPT10%(color.hardness.mlurack &gmin:imem)
clay S sand
4.Date Well(s)Completed: Well ID" 1 fr. I fa + 9r•ni:e
Sa.Well Location: { A. I n. I ,, C
Uwde ft. I ft.
JAinner jut i
Facility/OwnerNlamc Facility IDm(if applicable) ft. , fr.
1,519 L-H1 3ayw►tah Sy ltra. Q7�'7'7q rt. I ^l
L•Ka.
Physical Address,City,and Zip
Tr. ( ft.
r](D Ap-DO-rl ro:5
u ; 2t.RliiFL►RICS ter
J1 Coal'f i( i
County Parcel Idendficadon No.(PIN)
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(if wall field,one lottlong is sufficient) 22.Certification:
-3-5& 19-523 1, 0830 13- 493 W (D o?e alp
6.Is(are)thenell(s) Pet'manent or DTempomry Sio aturcofCcrnficdNell on,actor Date
By signing this torn.1 herecr certify-that t rrell(s)has(weir)coavtructed iR accordance
7.Is this a repair to an existing well: [3Yes or No ,salt 1S.I NC.-C 01C.0100 or IS.4 NC.?C 01C.0100 if'el/Corutrarrfotr Standards and that a
#"this&a repair,fd1 out kW K7t well construction information t lerplaia the nature.afthe ropy o(rhis record has been ptaeided to the hell owner.
repair under9?1remar/Ssectionoronthebackofdtisfemr.
p° 23.Site diagram or additional well details:
S.For Geoprobe/DPT or CIosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only IpGW-I is needed. indicate TOTAL N7UMBER of wells constnrcdon details. You may also attach additional pages if necessary.
1 drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: qa!5 —(ft-) 24a. For All Wells: SuGmit this form within 30 days of completion of well
For ntalliple wells list all depths il'diJferent(trample-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: �300 —(ft.) Division of NVater Resources,Information Processing Unit,
hlwaterlevel is ahove easing.use"=" I617 Mail Senice,Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells' In addition to sending the form to the address in 24a
above,also submit one copy of this form-MUn 30 days of completion of well
12.Well constructiod method: construction to the fallowing:
(i.e.auger,rotary,cable,direct push,eta)
Division of FVater Resources,Underground Injection Control Program,
FOR WATER SUPPLY NVELLS ONLY: 1636 NSaiI Service Center,Raleigh,NC 2 7699-1 63 6
13a.Yield(gpm) V N3ethod of test: w 24c.For Rater Sunniv S Iniection Wells: In addition to sending the form to
the address(es) above. also.submit One copy of this form %Atkin 30 days of
13b.Disinfection type; amount ide completion )c of well construction to the county health department of the county
where construet_d.
Form Gov-I North Carolina Depa:meat of Eavi:anm=n;ai C� a?iq-Jir?sio:.o:�:seer Rcsoccas Revised 2-22-3016