GW1-2022-08913_Well Construction - GW1_20220912

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: - Prlstt Four
I-Well Contractor Information:
Russell Taylor Ia.EATER ZONES
Well Contractor Name FROM TO DESCRipno
29 87-A fe$ r` 13 fL
NC Well Contractor Certification Number ft R.
15,OUTER CASING for mutu�sed wells OR LINER Of a to Hedden Brothers Well Drilling, Inc FROM TO otan,7sraR THICIVEss
Company Name ft ft in
r�?��' _ Q 16.INNER CASING OR TUBING eothermai eiosed-too
2.Well Construction Permit#: t�Da /• " qo? FRObt I TO I nLv►fETER 7ELfbirUr all applicable aril construction peen its ft.a U/C,County,5tateVariance,etc,- 12-R. a , ►n,3.Well Use(check well use): ftO C1/ inQ - .
Water Supply Well: 17.SCREEN O
Agricultural FROM TO mAht6TF.R SLOT Me THlCtOVESS DIATERiAL
'�1 E3Municipah?ublic fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply PP Y(single) g, tr. in.
In dustrial/Cotmmarcial OResideatial Wager Supply(shared)
18.GROTTY
Irrigation FROt! TO �tATERL►L Ea 1PL.10EMLNTMETHOD&A.SIOL4\T
Non-Water Supply well* fa 20 fL aaknae„�,, aumaed
Monitoring ORecovery n, fa
10cothermal
Aquifer Recharge 0Groundwater Rcmcdiationtt. tLuifer Stara and Reco 19.SAND/GRAVEL PACK if a licableA4 ge very 0,Saliniry Barrier ROttit TO MATERLtLAquifer Test. MStormwaterDrainage fL ft.Experimental Technology Subsidence Control ft.Geothermal(Closed Loop) 0-Tracer 20.DRILLINGLOG attach additional sfieets if necess(Hearin Coolin Return) Other(explain under#21 Remarks) FROM ro DESCRsendI Rotor hardness.saittrock ►n sloe.eta)
�^ it. � 70 fL clay a sand
4.Date Well(s)Completed: Well ID# f7o ft. fL I granite
5a.Well Location:
JjqQJncr l rr•�WTDt'Ll ft. ft. �. .,ti,.F�& 5 del LZ Li
Facntli tvncrNamc / Facility(BR(if applicable)
rL
Physical Addreu,City.and Zip R, ft. I
Ifq0-r:� en Un;l
s1p YSAW � ti.�stf "15 8 P7•a-01
21.RESLARKS VJ
County Parcel identification No.(PIN!
5b.Latitude and Iongitude In degreesiminutesisecoads or decimal degrees:
(if wall field,one ladloog is sufficient) 12.Certification:
Aq 35° 15.017 N 083° o5•��t W g L4 �a
6.I6(are)the well(s) permanent or 07ramporary Signature ofCtatificd%Veil Connector Date
I It By signing this fotru,l hereby certify that 4 u711(s)%vas Avere)conrtmard in accordance
?.Is this a repair to an existing well: O Yes or No u*h 15.4 NCAC 02C.0100 or 13 4,--- -0?C.-- iVell--m.action.Wndardr and ajar a
!f this 8 a repair,fdlout knottn will construction information rT erylotn the naurr..gfthe ropy of this record has been provided to the it-ell onner
repatrandrriti?1 tetnarbJeetioa oroathebaui ofthlsfamr. 23.Site diagram or additiottal 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 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
1 drilled: SUBMITTAL INSTRUCTIONS
9.Total vve0 depth below land surface: Sao (ft-) 24a. For Ali Wells: Submit' this form within 30 days of completion of well
For multiple er/ls list all depths tfdoerent lr.ratnp/r-3Q200'and 2@1001 construction to the following:
10.Static water Ievel below top of casing: 131f 5 (ft.) Division of Water Resources,Information Processing Unit,
Ifivatr level it abate casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter. (in.) 24b.For Infection Wells; Ins addition to sending the farm ro the address in 24s
„ IL above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 j�,.� I construction to the following:
(i.e.auger,minty,cable,direct push,etc.) �—
Division of t•Yater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: �� 1636,Mail Sen•ice Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) vlethod of test: 9.i�UKJ 24c.For Water Supply&Iriiection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form uritbin 30 days of
13b.Disinfection type: _ amount: completion of well construction to the county health department of the county
where constructed-
Form G%V-1 North Carolina Department of Environmental Q"alky-Division of W etcr Rcsoiuc�s Revised 2-22-3016