GW1-2022-07535_Well Construction - GW1_20220811

OHnf Fora
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor I 14.WATERZONES
FROM To I DESCIUMON
Well Contractor Name ! ft. ft
2187-A ft. ft
NC Well Contactor Certification Number IS,OUTER CASUgG for muttt•eased wells OBLIIVER(it able
Hedden Brothers Well Drilling, Inc FROM TO DfAAtErER rHICKYESS BIATeR(AL
i ft. ft
i
Company Name
q e 26.IIVNER CASING OR TIIBING eothermal closed-too
2.Well Constriction Permit#: of oju—o��LI — 1' I'rl 8.9 MINI TO ➢tuMErER TRlctcvess bliliT RIAL
UV all applicable urll cotcrttttetion pemi is ri.e.WC,County,State,Variance.etc) I. 0 ft. I ft /_w In.
3.Well Use(check well use): togf I I D' I in. AA
rE
[Industrial/Commercial
5h 1 Well: W SCREENPP y FROM To ➢rM1ETER SLOTSIZE TMCKNSSS MATERIALcultural C]Muaicipal/Pubiic fthermal(Henting/Cooling Supply) MResidential Water Supply(single) ft, ft. in.
Residential Water Supply(shared) I&GROIrrigation
FROM TO MATERLIL E,\IPLAcniENrMETHOD&A.1fOL4T7
Non-Water Supply Well: 0 ft I 20 it. I .6 piped
Monitoring [3Recovery Ft. ft.Well: ft. I ft.
quifer Recharge Gmundwatcr Rcmediation
I9.SAND/GRAVEL PACK if a ]ieable)
quifer Storage and Recovery DiSaliniry Barrier FROM TO "UTERUL E\fPLACE11tE\TJiETHOD
quifer Test E2StortawaterDrainage
ft. I is i
TechnologySubsidence Controleothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional shnFROM TO IDFSCitiPTtO\lrotor.)uzdaar.miUtvek a nSIM eta)eothermal(Heatin Coolin Retum) rJOthcr(explain under#21 Remarks)
ft. � _JW fL clay 6 sand
4.Date Well(s)Completed: 7 8 �� Well ID_' fr. fL
granite Fi=
Sir.Well Location: R, ft I
TX'Ji ' '&Dom Wol�'(;rceKTrce�w,rt ft. ft. I,
�-.
vEn
Fam1(ty/ \Tame Facility ID�(if applicable) ft. ft. I' Z L 5
,340 u_CK rr.
~
Olt
Physical Address,City.and Zip ft. I ft. I
(0$19 21.REMARKS
County T
Parcel ldencifrcation No.(PIS)
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees:
(if wall field,one(attlong is sufficient) 22.Certification: �.
J5° 11.8irl ji 083' 01.985 W P7
6.Is(are)the well(s) Permanent or Temporary
Simaturc of Certified Wcll Cant-mcror Date
e} B)'signing this torn+.!hereby certify that r rcrll(s),ras(were)eaartrueted m accordance
7.1s this a repair to an existing well: E)Yes or i�No whir ISA NCAC 03C.0100 or lS.,i,VCAC 0?C.0200 1Yt11 Consmrctfon Srandardr and Ilan a
#'OEt is a repair,fdl out broisn,yell construction infamration tdesFlain the Ball"..ofthv copy ofthis record has been Frovided to the well owner.
Fepairunder iL71 remarlasectlon or on the baa(-ofthisfomr. 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 1�W-I is needed. Indicate TOTAL ATUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below la //��nd surface. I V00 (ft-) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple w'r/Lr list all depria!fd/i fermt fevample-3Qa 200'and 2Q100') construction to the following*
10.Static water level below top of casing: I` —(ft.) Division of NV.2rer Resources,Information Processing Unit,
iftvater level is above casing.use'•r" 1617:tlsil Sen'ice Center,Raleigh,NC 27699-16I7
11.Borehole diameter. art.) 24b. For lniection\Veils: In addition to sending the form to the address in 24a
L�� h above, also submit one copy of this form within 30 days of completion of well
12.Well eonstruetiori method: ,1,-i construction to the fallo�vine:
C—auger,rotary,cabli:6 direct push.eta)
Division of Water Resources,Underground Injection Control Progratn,
FOR WATER SUPPLY WELLS ONLY: 1636 Al2il Service Center,Raleigh,NC 276994636
13a.Yield(gpm) i\-fethod of test 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the addresses) abovei also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
:�ilere cotLStrueted.
Form G1V-1 Nonit Carolina Depanmcnt ofErniranm mal Q'.:Iiry- Rcsou:ccs
Raised:�?-1016
I