GW1-2022-10807_Well Construction - GW1_20221209

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WELL CONSTRUCTIONNRECORDVV-1) For Internal Use Ottly.'
1.Well Contractor Information: ll
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Russell Taylor 1 14.WAT&BZONES I !
FROM I To i I I, DESCRI 011
Well contracm Nome i fL ` 1105- f7O
2187-A 1 ft. l fj
KC Well Coatnctor Cardlic etion Number I If.OUTER CASMG or multi sued wd b ORLUM ar to
Hedden Brothers Well Drilling, Inc FR0*M ITL! 1 h DIAMETER TMCK.YE55 NATMIAL
Company Name 116.LVNER CA51NG OR TUBING canal dosed-loo
2.Well Construction Permit#:glb 17- g048-9- laa61 FROM TO 1 1 DrA..mm TMCCMS atATBAtAL
Un dll apptleable aril tonSo%Mdon permits(t.r-UIC,Cermty,State;variance,etc) ft. 6 I ft W In, . , -re e-L
3.Wa Use(cheek well rise): �17.
I ; ft. 'n' r
Water Su Wells FROM
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Supply FROM To I ' DiAhtE1ER SLOTStZE Tfi1CKi1'ESS hiATERLIL
Apiculturdl �MtuticipaUPtsbtic ft,
n-
Gtaathwmal(Heating/Cooling Supply) oResidential Water Supply(single) fc. i ft im
IndustriallCommercial � es(deatiai Water Supply(shared) M GROUT
Irri lion FROM To i SPATE L E,1iFL1CF1tE\TsmmoD&A tOG,r
Tlon-Water Supply Well, ft. 201 fL I o s pumped
Monitoring Recovery ft. Et.
afectiom well: ft I ft
AquifcrRccIwgc E2GtouadvratcrRcmediation 19•SluYD/C,_RAVELPACK i[a Geable)
Storage and Recovery cisaiiniry Barrier FRCI:f TO I arATERLLL VNIPWCh1l:\T]tETHOD
Aquifer Test MStotawaterDrainage ft. l ( fG
FaaperimeataI Technolory Subsidence Control fr. I 1 n t
Geothermal(Closed Loop) C-Tracer 20.I)RILLLIGLOG attacbaddittand sheets if
Geothermal catia Coolie Return) Other(explain under t=21 Retaatis) FRoat To I neseRtntta�teeton toedo ntrec6 suss eoei
I lag) e 19� ;�, GaySsand
4.Date Wells)Completed:�T 'Ala ID
Sa.Well Location: ...
-t! m .
Ih e -
Fadl cr'Natae Facility M9(ifapplicable) fr.I R•
sul Racxdwe. R .
physical Addtess.MW.and Zip n 1 f[. 1 ( ft. In`^c- ?1^� i�Ei•r'x tF's�(![t!
S caum '7l01l' r7—511 ! �21.REMARISS
t pCuSoe� t i
County Parcel Ideatificatian No.(PIN)
I I.
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
[if Waa @eld.one 140gag is sutficicat) 22.Certification:
35 o aa-ik9 N 0S30 17.8)9 W JO
Sigtratutc afCecnfi Weil Caetrruor Dow
6.is(are)the wells) Pertnaaent or Temporary !
ay sigrriag tf:is fo�!hereby certify drat . +.rll(s/+ros(iverr)eaarrnrued rR aaoardar
7.Is this a repair to an existing welt: Dyes orP-112P
No HTdr!Sd A, 02G.0100 or ISd YG4C oleo200 ii'rl1 Caastractloa StarldardS dad du
!f this it a rapair,fdl out kaoxtr.vrlf epastruuloa iaformatiaelair.nce aatur ojrite copy of this record liar been provided to the tall ottaer
repairrmdiril!prmanir"W on open the backofrlusfaM- — 23.Site diagra.9 or additional well details:
8. iron may use the back of this page to provide additional Well site details or N
For Geoprabel33PT or Closed-Loop Geotbet maI Wells having the same
construction deiatls.'You may also atach additional gages if necessary.
nv consetion,only I GW-1 is needed. Indi=0 TOTAL NTMIBER ofnells I
drilled: I SUBMI MAIAVSTRUCTIOi\S
9.Total well depth below land surface: 50O A) 24a. For All t4eIIs: Submit this form within 3D days of completion Of v
Forawiliplrttrlislistalldeptlalfd{fjrtetrl(aamplr-3QI00'aad2Ql00') construction to the following
�nt I !
10.Static water laver below top of casing: V (ft) Divbsian of Nt ater Resources,Information Processing Unit,
Ifivaier/owlir above easbrg,use`-' Ib17 Slag Service Center,Raleigh,NC 1769 9-1 61 7
11.Borehole diameter- (ta) 24b.For In action R' W- In addition to sending the form to the address in.
till 1p ,.gam above,also n sultFa t one copy of this form Within 30 days of completion of c
Weil constraetiod method:_ j(e constructio to the follo
12. wing:
a-—gar,rotary,cable.Qvct push,etc) I t
Division o terResources,Underground Injection Control Program
FOR WATER SUPPLY WELLS MgLY: 1 36' 11 Service Center,Raleigh.NC 2 7699-1 63 6
13a.Yield(gpm) `J Nlathed of test: 34c For 1Vate�S looh•&Iaiection Welts: 1n addition m sending the fort
r the address(cs)i above, also submit one copy of this form within 30 day.,
I3b.Disinfection type: 3maunt canpledon of we&construction to the county health department of%be cot
tdeere eisnsnvet:d lI
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Fotin Gllr-1 North Carolina Depam ent of Emronm:n l Q:19ry-Div,A of%Vatcr Rcsoa=s Rued 2"1=-:
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