GW1-2022-10774_Well Construction - GW1_20221208

:_•'PrI�It�Fon
WELL CONSTRUCTION RECORD (GW I) Far Internal Use Only?
1.Well Contractor Information:
Russell Taylor 14.tVAMMZONES l i
FROM TO t DESC'UMON
Won Contractor Name
a ft. � I z� � E I I(�
21 87-A -
NC well Contactor Certification Number a i I5.O fL , ft. as-
OtTfER CASDiG for mum-cased wells) le
Hedden Brothers Well Drilling, Inc FRo�I To D1MisreR T1ttcicvEss NATEiWL
Company Name
�,�na_ ^ 16.DINER CASING OR TOBING ertaal elosed•ioo
2.Welt Construction Permit#• al P/ FROM To DL1SfEI•ER T 51ATOUQ
Lttt all applicable aril construction permits CI.a-UIC,County,SIV4 Varfawe,etc) I. 0 R. l aft. I to In
3.Well Use(check well use): ft I % _'• .Ise TE E I
RELN
Water Supply Well: MOM I nw+l= I sLOTSIZE Tl IMUSS MATERIAL
Agricultural IDMnnicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) it ft. i is
IndustrialtCommetcial DResidential Water Supply(shared) 1&GROUT
Irristation FROM TO MATERL L I LNIP ACE IMM-11[ETHOD S A\tOL1T
Pion-Water Supply Well: ft. 20 EL aaraa�s. primped
Monitoring oRccoveiy M it.'
1-C
action Well: fr. I fLquifcrRacharge 0GrotmdwatcrRcmediation
VELPACK Ha iieable)
quifer Storage and Recovery Salinity Barrier FROM TO SLITERLIL ntPL►CEb1MT 3-MMOD
quiferTest OStormwaterDra(nagexperimental Technology Subsidence Control fr• I fLleothermal(Closed Loop) Tracer 20.DRILLLtG LOG attach additional sheets if aeothermal(Heating/Coolin Retuta) Other(explain under-21 Remarks) FROM TO DESCRIPTION[Color.karaem.sotltreek a stm eft)
/� ft. I l� ft-i I ;clay&sand
4.Date Well(s)Completed: !Fell ID# I 3/ f` t granite _
5a.Well Location: '
ft. '� ft.�I , ��•'
�5
Faeiliey/Owa�a Vatae Facility ID-�(if aPplicable) i fG fL l OZ�
rim
�Ytru-r1U1 of'n
R. I ft.
Physical Address.City.and Zip
21.RESL►RKS
q o I n DUNTq l! 8u—.10a,43
County Parcel ld=dficadon No.(PL\)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wca field,one lat/long is sulytcicat) 22.Certification: i.
360 083° 95.M9 W i I JA
6.Is(are)the well(s} Permaneat or MTemporary
Sigpattuc ofCerdffcd Well Coptracror Oat
By sigrrfag ti:is jornr.!herrbr certify that r trra(s)Ira$(tKre)carw"cird in accordant
7.]s this a repair to an esisting well: MYes or No neap ISd ltiGiC 03C.QI00 or IS.4 VCAC rtructlan Standards and I/w/a
If rfib it arepair,fdl out knoatt rrr11 eoastruuion information Alexplain the nature of fire ropy ofrhis retard/ass been provided to the it-ell oarrer. y
repairfmdfr ire 1 rmuviaseetien ororr the bat,(ofthisfa m. a_Site diagram or additional well details:
S.For Geopr obe/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-I is needed. Indicate TOTAL A'UMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I Q�1 SUBMITTAL INSTRUCTION`S
V
9.Total well depth below land surface: p0 (fL) 24a. For .41
1
Wells: 'Submit this fo..m within 30 days of completion of well
Far multiplr wells Pelt all depths irddrrent(rxam171r-3Q200'and Z(j9100') consmuctioa to the following:
10.Static seater lcvvA- below top of casing: o (fr.) Division of N3raier Resources,Information Processing Unit,
lfivater/awl is above casinz use'-" I617 tilsit Service Center,Raleigh,NC 27699-I617
11.Borehole diameter._ Nate.) 24b.For Injection Weil§: In addition to sending the form to the address in 24a
above,also submit one copy of this farm within 30 days of completion of well
M Well construction method: Q L ft } , construction to the fellowing:
C—auger,may,cable,direct push.etc.)
Division of Fl ater Resources.Underground Injection Control Progmm
FOR WATER SUPPLY WELLS ONLY: �.✓�1f� 1636 Mail Service Center,Raleigh,NC 2 7699-1 63 6
132.Yield(gpm) N•3ethod of test: 24e.For Water Suoolv'S Iniection Wells; In addition to sending-the foray u
rrss 4 :he address(es) above; also submit one copy of this font within 30 days o
13b.Disinfection type: 1 1 Amount: completion of.yell construction to the county health department of the con=.
whera constructed.
North Carolina Deparunent of Eamimna»n:al Q:�iitt-DNU--io.o:\.attic Rcsou:cas R.•t7sed?�-3Ul
Form MY-I
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