GW1-2022-10241_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECORD (GW-1) 7tertl al Use Only:
1.Well Contractor Information:
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Russell Taylor 14.WATEBZONES
FRo11 TO DF.SCRIMON
Well Contractor Name Q ft. q "I a
2187-A ft 7 fad
NC Well Corttnetor Certification Number 1S.QIITER CASIIVG for mnitNeased wills O$LIIdEA le
Hedden Brothers Well Drilling, Inc I lotiz Ta DtMi Tittctc�tsss
l- ft. ftl tm
Coop
Coo ay Name
�1 Q n 2 I6.INNER CASING OR I DSING erlud elosed-ico
2.Will Construction Permit A �0aL'—4?08&b I' 100 7J FROM TO { nWiErEtt TaiC[GNM I MATEWAL
LW all applkable ut(l contarrelten ptaarfrs Cl.0.WC.County,stag variance,ate.) 0 n. 178 n1 1 W in vc
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3.Well Use(checkwelt nee): r18 ft. , 8 0 IL E In,
FA
SupplyWel: 1OM TO iDLAMEMM SLOTSiZE Tincla��ss am L
euitural �MutticipaHPub[ic tt ft. 1 hermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL strial/Commeteial DResidentW Water Supply(shared) GROLT
tion FRDAi TO i �tATERiAL EarPLACIMtE\T T ETROD&AMOUNT
Non-Water Supply Well: ft 20 n•1 ce.nanms> pumped
Monitoring, ORccovery77 R. fu
rejection Well;
ft. I fta
Aquifer Recharge 00roundwatcr Remediation
19.5lttVD/GRAVEL PACK tf livable)
Aquifer Storage and Recovery �Saliniry Barrier FROM To NLITERL%L F_NrPLACEr$1mr.NWMon
Aquifer Test tOStormwaterr)minage
Experimental Technology Subsidence Control fir. to
Geothermal(Closed Loop) 0-Tracer 20,DRILLI.IIG LOG attach additional.sheets if a
Geothermal Hearin Coolin Return) Other(explain under Ql Remarks tROtit To OeseRttrrto�tenor,turdaeu. ntroek a rim«ci
O• l rio M I clay S sawn
4.Date Well(s)Completed: Well l# 9 p fa fsj I Qmnite
Sa.Well Location:
y 111Y1� !'If]6� � ft. i fZ I
FacHiWO"crNeme Facility mnd(ifapplicable) fG l f;. l NOV I
Ar7 old Re= zaae_ of 877 1ca ro r
Physical Address.City.Od lip i ft. ( ft
�(]ctlCa,r, Conn ttii 71ay)"31-p8 76 + 21.RE8'
L4RK5
County Parcel ldcndficarian No.(PLti1 i
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one legions is=fficient) 2L Certification:
350 ?7. 83 0 12, 48.5 W IROQA
6.is(are)the 11e11{S} Pet maven[ or Temporary Signature of Certified tvcl,Convector Oats
By signing thisJarnc I helrbr cerlxh-that uell(s!•vas(weir)camoructed in aeeordoner
7.1s this a repair to tin existing well: C)Yes or No rich ISd NCAC 02C.010I or, VCAC 02C.0100!Fill Constraenon S7andardr and that a
!#'this It a repair.fill oat irnona wrll construction Information Arxptain the naturr.o(the ropy 0*1his record has bet n provided to the is-ell ou-ner.
repair under till remasla•sectlon or on the back ofrhtrfarm. 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 Geopcobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1�W-I is needed. Indicate TOTAL NVI�SBER of wells cottswcdon details. S ou may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �[A J A) 24a. For All Wells: 1 Submit this form within 30 days of completion of well
For multiple xsrl&Us.*all drpdtr tfdtTrrrni rcscnplr-3Q200'and 2QI00'1 constriction to the follbwing.
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10.Static water level billow top of casing: �� (fr.) Division of Water Resources,Information Processing Unit,
(fwairr/evil is aho"cmhrg.rue"+•- 1617 loll Scrvice Center,Raleigh,NC 27699-1617
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I1.Borehole diameter (tn) 34b. For Faieccion��!eils-: In addition to sending the form to the address in Zia
above,also submtt orie copy of this form within 3o days of completion of well
12.Well eonstructfoti method:��I�,j, con stntetion to the fol{o«'ing:
(L&auger,rotary,able,direct push.etc.)
Division of F3'ater?Resources,Underground Injection Control program,
FOR WATER SUPPLY NVELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
i3a Yield(gam) o ;•Iethad of test L.3/Wu� = -for Rater S- 8 Injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form utithin 30 days of
13b.Disinfection t)pr. _ Amount: completion of well construction to the county health department of the county
where constructed.
Fort O1\'-i ?Forth Carolina Depan=nt of Ensironmon:al Q:.lk,-DNsion o;'%'*z:rjRcsouuca Retired -_016
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