GW1-2022-08909_Well Construction - GW1_20220912

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VMLL_CONSTRUCTION RECORD (GW-I) For Internal Use Only:
I.Well Contractor Information:
Russell Taylor 14.WATERZONES
FROM TO DFSCRIPTtON
Wall COAttaetar Name O EL fG
Z'I BT-p1 p R. R.
KC Well Comncm Certification Number is.CUM CASDHG for multi-cased wells ORLlXM(Ife
Hedden Brothers Well Drilling, Inc FROM TO D1MtETER I THlci 4M I MA
ft. fL in.
Cotrrpa0y Name p p 16.DMRCASING ORTUBMG canal elosed-loo
2.Weil Construction Permit#: J6401-as m 15- 7 - (1 �i,51 FROM DIAM TO ETER TR�CECVESS d1A
List all appllt'abir Intl eanstruadon permits(t.a UiC.County,Stare,Variance.etc.) h• I 9 FL In. /s
3.Well Use(checkivell use): 59 f:. L rL in. . '8$ STE 6 L '
SCUM -
Water Supply Weil: FROh ITO I DiAAIErER SLOTSIZE THICKNESS atATERLIL
Agricultural C)MunicipaHPublic ft. ft. in
Geothermal(HeatingICooling Supply) WResidential Water Supply(single) CL fA f in.
Industriel(Commercial Residential Water Supply(shared) M GROUT 1
hTization FROM TO bt L FAIPLAMMENT METHOD&A►O tAT
Non-Water Supply Weil: M 20 n 6.140"U pumped
Monitoring Recovery ft, EL
nJection Well: fL I ft.
Aquifer Recharge r1oroundwatcr Remediation
19.SAND/GRAVEL.PACK if a IIeable
Aquifer Storage and Recovery M-Salinity Ban ricr FROM I TO I MATERLU. E?rPLACEf/tE�T METHOD
Aquifer Test C3Stortnwater Drainage I ft- I fL
Expetimm al Technology OSubsidence Control ft. I rt
Geothermal(Closed Loop) M-Traccr 1 20.DRM.LLNG LOG attach additional Sheets if sec
Geothermal Hearin olio Return) Other(explain under 21 Remarks FRONT To :clSy&rPTlo�Ieolor.bardaesr. N a n seas ate t
Q 0' u. EL !stay S sand
4.Date NYell(s)Completed: V Well M# X qOD f" amf111e
5a.Wall Location:
ft.
Jxfte, S kru ft. ft. C fit-.,ft.
Facility/Owner Name Facility 1Dm(if applicable)
l ;.-
Pond P,� rive d't J Iya- o?B779 EL ft. �
Physical Address.City.and Zip s- ft. ; ft. i! 2 _
ific1c5ow N-rl 76,99- 89-607 21.REh1ARICS
County Parcel Idencifieation No.(PIN?
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iaylong is sufficient) 22.Certification:
360 19.30 9 14 b8 3 0 Id- W g
6.Ware)the well(s) Permanent or Temporary Signature of Certiflcd Wcli Contmacr Date
By signing this fomt.1 herelry eert6-that narll(s)was(arre)coattructed in accordance
7-Is this a repair to as existing wait: [3Yes or No xv/t 15d NCAC 02C.0100 or I5.4 VCAC 01C.0200!Yell Com"c'ton Standards and that a
Jrth4r ita repair,fdl out knontt well construction information tdesplain the eatum of the copy orthis record has been prodded to the rrell cutter.
rtpalr under#21 remarks section or air the back offlisfornt. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1�W-I is needed. Indicate TOTAL N MBER of wells construction details. You tatty also attach additional pages iPneeessaty.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 900 UL) 24s. For.411 Mlells: Submit this farm within 30 days of completion of well
For nttitip/r wer&hest all depthr jd ffrrrnl irxamplw 1@200'and 2@1009 construction to the following.
10.Stacie water level below top of easing: 70 (ft.) Division of N''ater Resources,Information Processing Unit,
{/water howl lr above casino,use"+" 1617 Mart Service Centex,Raleigh,NC 2 7699-1 61 7
11.Somhole diameter. �_(ta) 24b.For Iniecdon Yells: In addition to sending the form to the address in 24a
- above,also submit one copy of this form Within 30 days of completion of well
12.WeU construction method: L 1t ;pus/� - construction to the following:
(W.auger,rotary,cable,Wrcet push,ete.)
Division of t.Yater}resources,Underground Injection Control Program,
FOR WATER SUPPLY NVIKLLS ONLY: 1636 Mail Sertice Center,Raleigh,NC 27699-2636
13a.Yield(gpm) 4 i-lthod of test: 24c.For Rater Sucaly i&Iniection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hpe: rt Amount: completion of well construction to the county health department of the county
where constructed. 1
Form GNP-i Atorrll Carolina Department ofEnMvnm.mrl Q"11hy-Dis'sior.of atcr Rcsou:� Rnised 2-�?-2016