GW1-2022-10746_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 1 14.WAMMZONES
FROM I TO i iDESCRiPTION
Weil Contractor Name ft.
2187-A ft. I �-
NC Well Contactor Cenilielttion Number 1.5,OUTER CASIPIG or mold-eased welbl ORLTNER(If ie
Hedden Brothers Well Drilling, InC FROat ft-
t To �'rnru+tEratt TMCJCNM MMRtAL
- fL !n.
Company Name 1 16.INNER CASING OR TQSING eathermal dosed-lco
2.Well Construction Permit#: �I o�aa FROM I TO 11 DtA,.M-ER TH(C UMS 91ATME
Luc all applicable arll consauctlon pe mftz(.�IlIC,Cowtry,State Variance,ere.) I. 0 f' I r7Q f,- (o- P Y C+
3.Well Use(check well use): 0 it, I a f` fI . ]AS S 7*66 L �
R F Water Supply Well: SCREEN
Obt I TO I DIAhtElt-R I SLOrSIZt: TFIICIG\'FSS 1tATERLIL
Agricultural E)MunicipaHPublic ft,
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft ft. is
Industrial/Commercial csidential Water Supply(sbared) 1&GROUP
bri Sion FROM TO IStdT6ttLtL E1iPL�t�dIElTIrErRODSA�IOCt\T
Non-Water SupplyWeii: 0 ft. I 20 ft. I anwatvvsse patnved
Monitoring - MRccovery IL tL
1"CCkathertnal
(Heatin Coolin Ret'um) M Othcr(ex lain undercation Well: fL I ft.
quiferRecharge MGroundwatcr Rcmediation 19.SAb GRAVEL.PACK ff a Iiga lei
quifer Storage and Recovery SalinityBarrier FROM To MATERraLquiferTest MStormwaterDrainageft.xperimental Technology Subsidence Controleothermal(Closed Loop) Tracer 20.DRIId.I:'G LOG attach additional sheets if a
FROM DFSC1LtP'rtO:k!color.Wsdnm.doatroek L nsta.tte)
#21 Remarks) fr. 1 fL i clay&sand
i m ( I
4..Date Weil(s)Completed: Well fLf graniteI 1 1��
.l
5a.Well Location: m.. 4.'a•..a =a L
ft, fr.,i
� csion 1 F
Facility IDS(ifapplieable) ft fL!
Facility/OwnaVatoc I -
LL CL1
Map-SlrrinA= in 8
ft. ft Iflivii7?uft^'il t r^C-3m' '
Physical Address.City d zip
MnODI, o►lru,g ��.� bea5 ,' �%.RLAI
County Parcel Idcatificarion\o.(PLN) ;
5b.Latitude and Iongitude in degreeslmiautes/seconds or decimal degrees:
(ifwoli field,one lot/ions is saffiicicat) 22.Certif cation:
36° l3.0?0?9 r( D8311ON�a?SI w o
— 5 Mturc of Ccnificd Well'Contractor Dm
6.Is(are)the wen(s) Permanent or 0-Temporary !
By signing tiffs form,I hereby certify chat t IIrJ1(sJ+V=livere)canatrueted in accordance
7-IS this a repair to as ec,cting well: Dyes or No isith 1SA NCAC 02C.0100 or 15.4 VCAC 02C.O200 hell Construction Standards and brat a
�thEr tr a repair fdt bat hnon�t Irrll earstrruufon information acplain the nature ojrtte copy ofthis has record beet:prortdrd to the is-ell
oer
repaieunder 921 remarleseriian orarr the back ofMisfarm. 23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geotbetutai 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 A'UMBBR of Wells
consuvedan details. You may also attach additional pa3es if necessary.
drilled- SUB-,AITTAL INSTRUCTIONS
9.Total well depth below land surface: bw (ft-) 24a. For All NVells: 'Submit this form within 30 days of completion of well
For multiple writs list all depths tfdirrent(example-3Q200'and 2Qa 100'l consirtction to the following:
i
Ia.Static water level below top of casing: )1 A (it.) Division of water Resources,Inforinatioa Processing Unit,
Iltvaterleval is above carfar,use"�" I617�lzil,SeniCe Center,Raleigh,NC 27699-I617
11.Borehole diameter* (Ya) 24b. For Infection!Fells. In addition to sending the form to the address in 241
�L above also submit one copy of this form tsidan 30 days of eompledon of wel
12-Wen cortstructioa PL method: L 1 LLJ�( L--�— construction to the fal1ot'6'ia9:
CU.auger,lowly'atbic,dlt push,eta) v Division of Water-Resources,Underground Injection Control Program,
FOR WATER SUPPLY HELLS OINLY: I636141faiI Sertice Center,Raleigh.VC 27699-1636
i3a.Yield(gpm} 13ethad of cesC e.i,.)w =4c-For Water Suooit•&Iniection_Weils: In addition to sending the form t
the addresses} above `also submit one copy of this foes: vlthin 30 days c
completion of.vela construction to the county health department of the coma
13b.Disinfection type: � � Amount: where constructed.
Form CNN-1 `larch Carolina Deparunem of Ea tn ti.oncnt l Qr i:ty-Di sin:.o:t:zicr Rcsou c� Raised 2-'?-1p1
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