GW1-2022-07530_Well Construction - GW1_20220811

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: PrintFon
7 L Well Contractor Information:
Russell Taylor 14.WATER ZONES
%11 Contractor Name — FROM TO IDESCIUMON
z1 s7-A I oft is it ;
It-
NC Well Contractor Catifieation Number
Hedden Brothers Well Drilling, Inc FFR,O tUTERC CASING formDA ETER� os�K(s BSATERtAt,
Company Name j ft. ft In.
S.INNBR CASING OR TUBING eothermal closed-loa
2.Well Construction Permit#: A=-4-7718-9- i)Ba3 I FROM I TO I DIAINIErER I Titrr:fcvess IAt uTeRut
List all applicable nt'll rorutrvct/on perni is(t.r;WC.Cow ay.State Variance,etc) I
� R. 9 ft In. Vc,
3.Well Use(check well use): ft m in.
[IndustriaYCommercial
Supply Well: 17.SCREErNFRORI TO MAMM-ER SLOT SIZE TIi1Ci\ 0. AIATERLIL
cultural 13Municipal/Public ft ft. in.
hermal(Henting/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Residential Water Supply(shared)Irrigation FROM TO MATERIAL J EtirPLAcF..t --rill HODd,LijoL1'T
Non-Water Supply Well: rL 20 fL pumped
Monitoring oRecovery ft ft.
injection Well:
� ft fLAquifer Recharge CroundwatcrRcmediati on Aquifer Storage Recovery I9.SAND/GRAVEL PACK u a livable)
Aqu' rage and Recov �Saliniry Barrier FROM I TO JLUTEAI.uL E\fPLACEblE\T?IE7HOn
Aquifer Test MStomwater Drainage ft. ft
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRA+I.I+NG LOG attach additional sheets if access
Geothermal(Heatin Coolie Return) ' Other(explain under#21 Remarks) FROM TO DFSCRIPTiO�tearor,tuzdoesr saturoek n stm etea
0 fr. 1 fL ! clay S sand
4.Date Well(s)Completed: Well ID;rIpCo ft I, granite
S .Well Location:
MaiJ� y I
Facility/Owner Name Facility IDS(ifapplieable) fc. I ft.
G-24 tt-dt hi"Iye, T�l,�,� rp _ a 8783
Physical Address,City.and Zip U ft. l ti S+tx^sl PlL c4kl v
JACral
XSw CZU T-4 04*8 ' 21-REMARKS r
County Parcel ldcn�frcation No.(Ply)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) .2.Certification:
350 13. 71t •I 0830 00. %) W '1 16
6.ls(are)the well(s) permanent or MITemporary Signature of Cerrificd Well Contractor Date
p� By signing this form.1 herebv certify'Thal r ar11(s),rag(»rrc)rnartraeted in aemrdance
7.Is this a repair to an existing iveLk n Yes or No l,idr 154 IVCR.0 0?C.0 too or 15.4,VCAC 0?C.02 In Mell Consourrion Standards and drat a
/jrh&it a rrpoir,jdlou/knoan wr11 construction injormrarion tdesplair,the nature ofrhe copy ofthis record has beer provided to the ittl!onner.
rrpoir under AV I or on the back ojrhir farm.
13.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 I OW-1 is needed. Indicate TOTAL N MBER of wells construction details. You may also attach additional pages if necessary.
drilled: J. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (POO A) 24s. For .AII Wells: Submit this form .within 30 days of completion of well
For multiple ire/ir list all depthr r'ldierent ri:rample-3@?00'aand 2@100') construction to the following:
10.Static water level below top of casing: W (fr.) Division of Water Resources,Information Processing Unit,
jfivairr 16e1 is ahoy easing use'=" I617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: (in.) 24b. For Injection WetlSa In addition to sending the form to the address in sea
above, also submit one copy of this fom tsithin 30 days of completion of well
12.Well construction method: Lh, 1� construction to the followiag:
C—auser,rotary,wble,direct push,etc.) V
Division of Waver Resources,Underground Injection Control Program,
FOR WATER SUPPLY\VELLS ONLY: 1636 Mail i Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_Q? Method of test, 24c.For Water Sunoiv fB'Iniecrion Wells: in addition to sending the form to
i�1 I the address(es) above, also submit one copy of this form nithin 30 days of
13b.Disinfection type: X i-1 amount: 1oga completion of well consiruction to the county health department of the county
where constructed.
j
Form Q%V•1 North Carolina Depatment of Erivi anmcm-al Q:af ir`•-Di•:•s.'or.of v:zmr Rrsou ces Raised 2-'_-1016