GW1-2022-10777_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GAY-1) Far Tntemal Use Only:
1.Well Contractor Information: k
Russell Taylor i 14.WATERZONWI
FROM TO t I I DESCRirnw
WcU.Coaa=Na= I
2187-A �19 15
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!IC Well Contractor Cc tifrption Number i 15.OUTER CASING r mold-cased-Vib ORLIlVER(If k
Hedden Brothers Well DdIling, Inc 1 FRONI To DIAMETER TFIIClt:ltSS POTURE
i- fL fG l in.
Company Name 1 16.LNNER CASING OR TUM-G axed daseddoo
2.WWI Construction Permit#: Dl a'P FROSt To DIANTETER TMOCVSSa NATZRML
Ltt!all app(trablr wdl tvartrttedon permits(.r.U/C.Canary.State.Varic-a,etc.) �. ft. I iL
3.Well Use(check Wail me): i ' ft: 11,16 ra 1 m I . 188 T96 L
lGeothwmal
�tpply Well* 17.SCRBBN
FRiom TO DI MMIR SLOTSIZE THICl4 M TMUAL
uitttral E3MunicipaMblic fe ft.E in.
e C-4(Henting/Coolittg Supply) R)ResidetttW Water Supply(single) ft. ft. ]o.
triaYCounaccial Residential Water Supply(shared) 1&GROUT
lion FROM TO I NIATEMAL i 51FLA290-F31mobEM51OL01
atareupplyWell: ft za 2 Ctanaad
toring Recovery IL fLon lYelI:f-R c DGrvtmdwatcrRcmcdiationazBI9.SADtD/GRAVEL PACK if Iiesble)
Storage and Recovery �Salini yBarrier FROM TO �L1TMUA ESIPLA EllfihTDt]iTTttoD
ferTest 0StormwaterDrainage fL I ftrimental Technology Subsidence Contra! fr. I ft.etmal(ClosedLoop) Tracer 20.DRMIXN-GLOG z=FjAaddidonal3heetsllahermal(Heatin Coolin Return) Other(explain,under.-21 Remarks) FROM TO
I DFseRtt*rtoa teotor.tnrdceu�oQtrsek � rlLs ere I
0 % 1110 •fL I clay a sand
4.Date Wells)Completed: 6 Well I:D '1 I 0 fr- :rt-
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Sa. nnYV.
Well Location: cr. fL
Rill I.Am 1P n
Faccairy/ov==Namc r Facility M;T(ifapplicable) I fL I fr. �' -
IP,YYL11 YYQnwrr� .22-13 ' , rL =L I a
Fbysical Address,City.and Zip ft. -
°S Rfi�FARKS ..,•o.^:nic�f�l_i i
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County ?nrcci Identiftcation No.(P12N) e+ -- —
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees: ---
(ifwall field,one 140003 is suRiei=t) %2.Certification:
6.IS(are)the Wells) Permaneat or Temporary
Sigtmtutc of Ccrdfscd�Ycll Conffaaor Cm
dy s.'gniag zi:isDorn:.I herrQ:-certif-that IrF1I(s).rw ntrre)eo owed in accord
7.Is this a repair to a4 existing well: [3ye9 or !o Is all ISd NC6C OX.0I00 or IS.-1 VCAC 02C.0200 VeM Coaraurif-9andan&and 11
f rh&i7 a rrpofr.f i out Main Ivr11 CanstrueriOn infarmartaa lerplain ere raters of the ropy oft%:ii record ire been provided to the 1re1/oxner.
repair mtdfF921 re w*jeuion or air the baakofdiisfmm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I( -I is needed. Indicate TOTAL NUMBER ofm-alls cotssuuction details. You may also arch additional pages if aeeessery.
3W
drilled: SUBMITTAL INSTRUCTIONS
9.Total mall depth below land surface: 50 (ft-) 24a. For 41l Neils: St:bmit this fort within 30 days of completion of
For maldpir ttr/Ls rat all depth:ifdrfferent iesamplr-3Q200'and 2@1001 corsrmcdon to the following:
dd i
10.Static inter level below top of casing: �Uf� (ftJ Division of NVater Resources,Information Processing Unit,
Ifivalm l w/U above oaring use"-" 1617 Mail Serszce Center,Raleigh,INC 27699-1617
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11.Borehole diameter. q-) 14b. For Iniectfl n+R'etls4 in addition to sending the form m the address h
h ^ above.a)so subtatt lone copy of this form within 30 dsya of ewopledon of
12.Well constructlod met add: 1 h construction to the following:
CU.auger,rofmy.nble.diteet push,cte) I I
DIN-islon of A"aterResources,Underground Injection Control Prograi
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sersice Center,Raleigh.NC 27699 1636
13a.Yield(gpm) Nlethod of test 1 24c.For Nate J Suonly g Infection Wells: In addition to sending the fo
the addresses);above, also submit one copy of this £oast within 30 da
13b.Disitsfection type: r Amount:
conpiction of well construction to the county health department of the e
tvnere eonsttuot-d.�
Fern ON--1 -North Carolina Drzar=nt of fit-vimnrrcntal Q"U •-Divs:I.-.o:t:near