GW1-2023-00785_Well Construction - GW1_20230112

WE
LL CONSTRUCTION RECORD (GW.1), For Infernal Uie OnIF
I.Well Contractor Information; I I
-----------
Russell Taylor ZONU
Wd Connector Name I
F FROM I TO I i DRIERIPHEN
q rl t, 1 60�
2187-A I I !
K Well CoaRactor Cctification Number J A N 1 2, 2023 -0 0
819 UTER ING CAS (for mulff-casad welbl ORIMER(IfEESS Ule
Hedden Brothers Well Drilling, Inc. FROM To I
P1jV_'�D0_)Z I- DrANLTM I DTATOUAL
COMP20Y N=5 n1VVQ"3' 0rj f I
16.M-MCASING ORTIMING(reatherm.1 glawd-1—an
2-Well Construction ParmiM 4wo-aawl-cl- 10b8a FROM I To_1-T I DE41NMTM I TMCX.%,= IntATERut
WC.Cbtorly.SW4 Variartrg,etc.) in, 1 1
3.Well Use(check wcH use); ft I ft in,
Water Supply Well: 17.Sr.FZ&N
FROM I TO I DMLMZ7 I SLCFTSIZF I TMCMMW NUATERLAL
Agricultural [3Municipal/Public ft,
C—thcr-al(Heating/C—ling Supply) WResidatttial Water Supply(single) ft. I In.
IndusuialtCommerrial DResidcatial Water Supply(shared)
I&GROUT
Irriitation FRO51 To I ATATEREAL I EMPLACnMT,%lErH0V&A3T0
NOR-Water Supply Well: ft. zo I ft-
Motrito:irrgORecovery I ft, ft.
Lecuon Well:
144 A fr. ft.
lAquifarRocharge DGrouadwator-Rcmediation 19.SAND/GRAVEL I L PAC I K(Ifavulleable!)
Aquifer Storage and Recovery MiSalialty Barrier FRom To MATERIAL I MIPLACM10"rMEMOD
quifer Test [3StomawatcrDrainazz
Experimental Technology OSubsidence Control
C=thetmal(Closed Loop) M-Tracer 20. 'GLOGf6ttachadditional3beetsift
— Geothermal(HeatIng/Coc1inF Return) [3Other(explain under#zi Roma tits) FROM I TO I DESCRIPTION
1176 fl- ! clay&sand
4.Date Well(s)Completed; Well IDS !Z0 fr. sd:l 1Lgranite
I t
S2.Well Location: ft. I
'r. ft.
KiMberki 16+er_-All
FacilitylowncrNarac Facility 133S(irapplicable)
ft.
LIN &=b-rrw- IA. L)hA,,-. JEWS)
Physical Address,City.and Zip rc. ft,
L6gsw Comi-rg r71o11-=?0-9V(9 21.RE&LAIM
C-UY Parcel Identification No.EM) i yaxiG?, biel I
5b.Latitude and longitude In clegrealminutes/seconds or decimal degrees:
(ifwcu 50111,one 140cag is sufficient) 2L Certification:'
350 0?1. 081 . 100 il)
08Y 19 W
— A I.?k?
6.Ward)the well(s) armanent or E3T=porzn, Slwmvarc of Ccrdgcd NVclI Contractor 0=1 I
EAP I
'6ydgn1ffg:1'(s.12M4:lhere4-cerij5r that r irr4r(cj iras(tverr)cowncirdift savord7l
7.Is this a repair to an existing well: [3Yes or No Isith 15A MC-4 C 027C 1
FrPV*;fld1 091 AnD I W72 ivell construction information idrsplair.the naturr-qr1he cqFW qrthis record has been prvr7drd to the hell owler.
neptrip and4rr Oil remarla jewion,or on the back ofthisfam.
23.Site diagram or additional well details:
S.For GooprobaMPT or Closed-Loop Gootbarmal Wells having the same You may use the back of this page to provide additional well site details or
construction,only I OW-1 is needed. Indicate TOTAL NMNIBER of wells construction ,You You may also attach additional pages if necessary.
I
drilled-_ 1 nn SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For Ml Wells Submit this form within 30 days of completion of
F;7r=1hple stvl&I&t all depths 1fdrirmi(r=mj7lr-3@200'and 2@10011 construction to*following.
10.Static water level below top of casing: &D Division of I'Vater Resourceg,Information Processing unit,
ffivalor Iml it abow=Ing.uw 1617 Mall.Service Center.Raleigh,NC 27699-1617
IL Borehole diameter.
24b.For lnlecrlp�n Wells;. In addition to sending ibe form to she addrcw in
M Weir constructiod method. LQ above,also submit one copy of this form within 30 days a completion of v
Cta onstmcnort to thi following:c"Gar,rolary,cable,direct push.etc.) t !
Division of VNIat§r Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS MNLY: 163.6 Mall Service Center,Raleigh,'SIC 276YP-1636
13a.Yield(gpm) 3D IN-lethod of test. 24 rr� he addresses)
For Water Su'oplv 9-Injection Wells; In addition w sending the fbrr address(es) above; also submit one copy of this form within 30 day.
13b.Disinfection*.PC; Amount: completion of hell)construction to the county health department of the coi
za I %%,nor::coaStractcd.. I
Form 0%1'-1 North Carolina De-partmem off-E-m-tranw.zmal Qtzifty-Di-Esicnioz-%Vatcr. Rcsowr= Raised 2-2-1.: