GW1-2022-08199_Well Construction - GW1_20220516

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WELL CONSTRUCTION RECORD (CW-1) For Tntemal Use Only:
1.Well Contractor information:
Russell Taylor 14.WATER
Well Contractor Name FROM TO DESCRIMON
2187-R 186 it 19 0 n
ft. ft
NC Well Contractor Certification Number
IS.OUTER CASING for multi-eased wells OR LINER(If unallvable
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER rxtctcvEss matlRtAt
Company Name R ft i in.
/I0 19r� -9� 3(Op 16.INNER CASING OR TUBING(eothermal
t: closed-loa
2.Well Construction Permit Gl 7 FROM To DIAMErER TmrF0 Ess MArERtAL
List all applicable urll consmicilon pern'its(t.c 07C,County,State•Variance,etc.) 0 it. 13
R In. ,/I Y
3.Well Use(check well use): 4 it. I 3 ft. in.
Water Supply Well: 17.SCREEr\
A cultural FRObt TO DIAMETER SLOTSiZE T UCiQYESS MATERIAL
E3Municipal/Public ft. ft. in.
Geothermal(Iienting/Cooling Supply) Residential Water Supply(single)
—ft. ft. in.
IndusuiatiCommercial oResidential Water Supply(shared)
18.GROUThTi tlOn FROM I TO NIATEFuAL EMPLiCEN10FliETxOD S A310
Non-Water Supply Well: 0 11- I 20 EL ,M pumped
Monitoring DRecovery, ft. ft.injection Well:
Aquifer Recharge Groundwater Rcmediation fL I ft.
Aquifer Storage and Recovery ��'-yy;Sa[ini Barrier 19.SAND/GRAVEL PACK ira Gcable)
r� tY FROM TO MATERLkL I EXPLACENTENI'METHOD
Aquifer Test OStormwater Drainage ft. I is
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRII.I.L IG LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) Other(ex infra under�21 Remazks) FROM TO DESCRIPTION(color,lrordnesu sall/roek r rain size.etc.)
C f4 I clay 8 sand
4.Date Well(s)Completed: Well M4 l` ( 5 f` I granite
go.Well Location: fc. ft. i
� - fr. ft. f
Facil(ty/ -Name Facility IDO(if applicable) ft. fr. I P
�ai�5 Bw►1 P� Rd. � �; + a 7l� ft.
2922
Physical Address,City,and Zip fr. I ft. w1fo abw Pf Uno
i
'4 r7 p. 9,-r�c zt Zi.REMARKS
County i Parcelidcntihcarion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field.one Iavlong is suRicicm) 22.Certification:
t 35° 0)--g o .t 083° 05. 4,95 w
6.Is(are)the wcll(s)f kpermanent or ©'iTemporary Signature of Certified Well Contrdclor Date
By signing this farm.1 herrbr certify that r urll(s)nws livere)conrinrcted in accordance
7.Is this a repair to an existing well: nYes or No t,ith ISA NCAC OIC.O/00 or IS.a NCAC 0?C.0100 IL'e/l Consimelion Standards and Mat a
!f this is a repair,fill out knonst,veil eonstr7,ction information rdeeplain the naturr-of the Copy of this"card has been provided to the well order.
repair under 921 rrmar)5 seraion or on the back ofthisfarnr.
23.Site diagram or additional tveIl 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 t CIW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: r n�. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of(veil
For multiple urfis list all depths iftfi ferew(kramp/r-3@200'and 2Q100'l construction to the following-
10.Static water level below top of casing: 1,10 (ft.) Division of Water Resources,Information Processing Unit,
If water lour!/s above casing,use"_" 1617.Nlait Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: (in.) 24b. For Infection Wells; In addition to sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this form within 30 days of completion of well
(i constructionconstruction to the following:
.e.aug
er,rotary,Able,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l� }Method of test: 24c.For Water Suooiv B Iniection Wells: 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: amount: � �0 D� completion o;well construction to the county health department of the county
` where constructed. j
Form G«'-I North Carolina Department of Environmental Quality-Division a,R'atcr Rcs lances Reused?'�-1016