GW1-2022-10201_Well Construction - GW1_20221111

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WLLL CONSTRUCTION RECORD (GW-1) For In al Use Olily:
I,Well Contractor Information:
Russell Taylor 14.WATERZONES i
FROM TO DFSCRIMOT
WellConaaetor Naha fc. � ,
2187-A
Iwo �
NC Well Contractor Cantif=dau Number 15,OUTER C;6§ViG or rant ed wells ORLII4ER tabi9
Hedden Brothers Well Drilling, inc FROM Ta DIAMETER T► C—J0 ss mA
TJMML
Cortrpany Name I6.ONNMA CASING OR TMING ermal elosed4oa
2.Weil Constrttcdon Permit#: FROM To I I DIAMETER I TIFFICEFIM I 31ATZE"
Un all applhmble arll wittauedon permits Cl.a.WC.County,State.Kujanee,eta) � K• t !n. PVC,
i i':'V
3.Well Use(check well use): . 13811- 140 1 tL IU . 188 1 IS TEKI. '
InNi'iaW
ater
Supply Well: 17.SCREEN
FROM TO I 1M DtEfER SLOT SIZE THIC[01'ESS Ml1TlOtIAL
Apflettlturdl [IMunioipaMbiic tt 8. is
Geothermal(Henting/Cooling Supply) OResidential Water Supply(single) ft. ft.I in.
ndustrial(Commereial Residential Water Supply(shared) 18.GROUT i
Irrigation FROM TO MATEPIAL I E.M Pt.ACf1i MT.I LTHOD d At 04TT
- aterSupplyQVeil: ft I 2a am.nsouaa aamved
Monitoring Recovery K.ecnon N ell: ft R
Aquifer Recharge C]Qroundwatcr Romcdfation
Aquifer Storage I9.SAND/GRAVEL P Ira 11 a
Aq rage and Recovery �Saliniry Barrier FROM To iSUTE-- I LXPLACEML%.r zTHOD
Aquifer Test OStormwater Drainage
Experimental Technology OSubsidence Control rt•
Geothermal(Closed Loop) Tracer 20.D LOG Anacb additional sheets it access
Geothermal (Hearing/Cooling Return) MOther(explain under_21 Remarks) FROM To DESCRiPTta% color.hardnemsott/racIt sirs.etas
ft• l J� �fb clay t:sand
4.Date Well(s)Completed: Well IN i (� fa 1 Tt I granite
5 W H Location: R. 'K• l
Facility/OwncrNNnar__n__c,�, r Q FacilirylDe(ifapplieable) fG IK•
�IirrY rU�I�WL R415 8t .CiN. o?B 913 r� �cr.
Ph+ital Ad sew.City.and Zip
!au(v9 001 B���o ! �1.RE&IARIGS .
Couary Parcel idendficadon Xo.
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees: i
i
(ifweti field,one lat/long is sufficient) 22.Certification:
35° is. 90 0830
6.Is(are)the wells) Permanent or OTemporary Signature ofCadfled tV it Contactor Me - Oatc
2j sigrriers this fame.!l�erebi mrtijy that t urtlfs)bars A eir)eaariructed/n accordance
7.is this a repair to an existing wall: MYes or No Isltb ISA NCAC 02G.0100 or, 4 vCAC 03C.0200 05,H Consnnetion Standards and tlia/a
lf(his it a repair,fdl out Maim ivrll construction informationA.I.P1-in the nahtrr-of the ropy anhis record It=bi en presided to the iseil ouster.
repair under 921 ren atkssecdon or air the back ofthisfarm. 23.Site diagram or additional 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 I OW-1 is needed. Indicate TOTAL N MBER of wells coasuucdon details. �ou may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIQ\'S
9.Total well depot below land surface. 60 (ft-) 24a. For N1 Wells Submit this form within 30 days of completion of well
For nuritiplr urns list all depths ifdFffrrew tr=nrplr-3Q300'and 3Q1009 construction to the fo lowing:
10.Static water level below top of casing: (ft.) Dhision ol'Ni°titer Resources,Information Processing Unit,
jlsvatm level Is above eatirre,use'•+ 1617 3Iall'Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter. (in) 24b.For Infection Yells:. In addition to sending the form to the address in 24a
t.. above, also submit dne copy of this form,"ithin 30 daya of completion of well
12.WeLL construction method: Construction to the fgilov�ing:
(Le.auger,rotary.cable,direct push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY jW/nE�LLS ONLY: 1636 Mall Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) 1 aL 1Iethad of test: 24c.�F_o_r_R�a_t_er_�uPly&Infection 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 t)pe: Amount: _ completion of well construction to the county health departnient of the comity
where constructed. !
Form G1V-I Nonb Carolint Depawnent ofE:ttironinan zi Quliry-Division of iNVver Rcsowc.s Revised 2-21-1-io16
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