GW1-2022-10202_Well Construction - GW1_20221111

Prit tF0M
WELL CONSTRUCTION RECORD (GW--11 For Intemal Use Only r
1.Well Contractor Information:
i
Russell Taylor 14.WATER ZONES !
FROMTO { PIZMMON
Well ContracrorNama 1,245 ` ,Q 2187-A
ft. I ft I'
NC Well Contractor Certification Number 15.OUTER CASIIVG of mulct-steed rolls ORLzaaaf a silk
Hedden Brothers Well Drilling, Inc PROMt I TO I I 111AMETER i TWCIcam MAT6lt1AL
ft. ft; In.
Company Name
16.LVNER CASING ORLTMWC; eothwmal cl""-I ro
2.Well Construction Permit#: FROM TO MME ER TAtCICYSSS At
LfitalJappftcablr tall trottstructton permits(i a MC County,State,Variance,etc) I. 0 ft. In Iti In,
3.Wen Use(check well use): ft ftl in.
Wa-GSupply WeII: FROM CM&to 11i DtAMtErER SLOTs1ZE TfnCt4VESS 26IATEAL1l
Agricultural rIMunicipal/Public fa ft. in
Geothatami(Heating/Cooling Supply) MResidential Water Supply(single) fc ft. is
Industriel/Commereial ORcsidential Water Supply(shared)uPP Y( are 1&GROUT
1[ri lion FROM TO I JIATERL►L En! LAMBENMEMOD A.313U.T
Non-Water Supply Well: ft ?A rsnusaerra. pumped
Monitoring Mpecovery 1•L f
ejection ell: fL
Aquifer Recharge 00roundwatcrRcmediation 19.SAND/GRAVEL PACK 1fa Iicable
Aquifer Storage and Recovery Osalinity Barrier PRO Mt rn stATEAU MPWCEDtr-%r5 -M3D
Aquifer Test M-Stormwarer Dminage ft,
Experimental Technology OSubsidencc Control rc. I iF
Geothermal(Closed Loop) M-TmeeT1 20.DRILI MG LOG attach additional sheets if necessary)
FROMTO 1DESCRIPTIO\teotor.hardaess,sotttroek a slwete.
Geothermal(Heating/CoolingReturn) Other(explain tinder--21 Remarks) ft. if i clay 8 sane
4.Date Well(s)Completed: Well M4 � fr. I g�i di � granite
5a.Well Location:
i
Fae{lity/Owa 'V FaciliryIDc(ifapplieablel
AntEL
r Sc)n C. r]i
Ph sicalAddd..City.and Zip �+ p i ft' R InfOf1+n"-.1 Pr'' unq
RKS
44t39 1 21.REMFA t
County Parcel Identification No.(Pr r I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if Wall gold,one inflong is sitfiicicat) 2«C rtification:
MO i8.8S9 x _ 083` J2- "Z W jp doaa
Signature of Ccrtifted vvc I Contractor Due
6.Ware)the weil(s) PetTnaneat or Temporary
t3j signing this fornt 1 htn6t certtjy that a 1+r11(s)teas h+rr/con•rradvd it axordanet
7.1s this a repair to as eslsting well: L]Yes or No xidt 15A NCAC 03C.011 0- -- -,VCgC 02C.0200 Irel/Construction Standards and that a
{f this tr a relwlr•Jill out kno»n curl!construction informationA.P7aintheaturrof thecopy a this re
cord irLto rriter.J211out knomi wril construction infamation cord)tits birn prntfdrd to the trill ontrer.
ngairunder 021 remarlasection or on the back ofthrsfann. 13.Site diagram or a ditlonal 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 1 OW-1 is needed. Indicate TOTAL N-T&LBER of wells construction details. 11 ou may also attach additional pages if necessary.
drilled: I Q SUBMITTAL 1NSTAUCTIONS
9.Total vveII depth below land surface: V DO (ft-) 24a. For All Wells:I Submit this form within 30 days of completion of well
per multip/r trel&Ma all depths itddrrent t rowitle-3@200'and 2@100'1 construction to the following:
r
10.Static water level below top of casing: (ft.) Division oflWater Resources,Information Processing Unit,
JftvaterJewlls abovr caring,use'•+'• 1617 A;ail Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter: _(la) 24b.For Injection\Vel6; In addition to sending the form to the address in 24a
n ^ �� above, also submit o e copy of this form nithin 30 days of completion of well
12.Well construction method: h I�l� i construction to the following:
(Le.auger,rotary,cable.direct push,etc)
Division of\Vatei•Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 itiFari Service Center,Raleigh,NC 27699-1636
1316 Yield(gpm) M3ethad of test: 24c.For\Vacer Sal )election Welisr in addition to sending the form to
the address(es) above Jaiso submit one copy of this form vvitbin 30 days of
13b.Disinfection type: _ Amount: 1 completion o2 h department of the county
when constructed.
Form OW.I North Carolina Department Gf Emiwn=nW Q:..a4�,•-Dic:sior.of tvzt'cr Resources Revised 2-2-1-2016
i