GW1-2022-08210_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD (GW-1) [For Intemal Use Only: i — -
1.Well Contractor information: i
Russell Taylor 14.WATER ZONES
Wcll Contractor Name FROM I TO I DESCRIPTION
21 87-A g f1. 1Rg
ago ft. am n.
NC Well Contractor Certification Number 15.OUTER CAS3IVG for multl.c�ved Ive1LS ORLINER(if applicable)
Hedden Brothers Well Drilling, Inc FROM To DIAMETER THICFC ESs I MATERIAL
i ft. ft in.
Company Name
16.INNER CASING OR TUBING(geothermal elosed4oa
2.Well Construction Permit#: 01 oa l—P FROM I To I DIANIrmtt I TRiCh�fEss MATERIAL
Ltst all applicable is-all consirriction pen nits(.e.WC,Calmly.State.Yariance.etc.) � ft. I � ! it ln- `��
3.Well Use(check well use): 7 ft. r7 fr. in. I 8 Y F L e
Water Supply Well: 17.SCREEN I -
FROM TO DIAMETER SLOT SIZE THICK14TM I AtATER1AL
Agricultural []Municipal/Public fr. ft. in.
Geothermal(Henting/Cooling Supply) OResidential Water Supply(single) ft. fr. in.
IDdustrial/Commereial OiResidential Water Supply(shared) I&GROUT
Irrigation FROM TO I bIATEM Elt LAACEIIE\T,ItETHOD S AMOUNT
Non-Water Supply Well: 0 fr. I 20 fz eeeenaems,: pumped
Monitoring ©iRecovery ft. ft. I
njection Well:
ft. I f4
Aquifer Recharge Groundwater Rcmediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO J LI LITERL I EXPLACEME\T METHOD
Aquifer Test 0-Stormwater Drainage ft. I fr
Experimental Technology Subsidence Control ft. I it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To I DESCRIPTION(color,hardness.sollfroek tVPL grain size.etc.)
QQ n 0 ft Ito 9
ft I clay S sand
4.Date Well(s)Completed:tJ of Well ID.' I tact ft 1300 fL I granite
So Well Location: R. ft. I
Ift. ft.
Facility/Owncrsame Facility[Da(ifapplicable) ft. 1 ft. I ,�:-
I, I rt. -
Pltysical Address.City,and Zip fr. I ft. f _
�Yl� Coyorl g5A+i6117r7J'8 I21.REXARKS
County Parcel Idencifrcat(an No.(PIN1 (�/� �'if .��•+ '[''
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field.one let/loag is SuRicient) 22.Certification:
_350 a5.010 ,t 0830 11. le314 w
3 )31 o?oa
6.Is(are)the well(s) Permanent or OTemporarT Signature of Cc-ttified Nell Contractor Date
By signing this join+.I hereby certjjp•that t well(s)w•as(tsr)r)coaanrcted in accordance
7.Is this a repair to an existing ivell: nYeS or No with 15A NCAC 02C.0100 or,IS.d VCAC 02C.0200 Mel!Construction Standards and Iliac a
J'llds is a repair.fill out know;ivell construction infortnaion rdesplain the none"ofnhe copy afthis record has beet:proidded to the well owner.
repair under#21 rentarla section of on the back ofthisfomu_
23.Site diagram or additional well details:
S.For Geaprobe/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: t SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: 300 (ft.) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew iaramp/e-3@200'and 2@100'1 construction to the followine:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit;
If rater level is above casing,use'•_" 1617 3Iail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wails: In addition to sending the form to the address in 24a
L above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: �Q- _ /')1 • construction to the following:
(i.e.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
13a.Yield(gpm) a_5 Method of test &MID For Iti ater Suopiv 8 Injection Wells: In addition to sending the form to
ie addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type:_ Amount: � �0 completion of well construction to the county health department of the country
t here constructed.
r
Form GIV-1 North Carolina Department of Entiranmcntat Q•miry-Dicis:o.-.oflCzrcr Rcsourccs Revised 2-2_1-2016