_Well Construction - GW1_20230320 (56)

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. WELL CONSTRUCTION RECORD (GW-1) For Internal Use OnIy:
1.Well Contractor Information: I -
1.
Russell Taylor 1 14.WATER ZONES
FROM l TO DESCRIPTION
Well Conoco!?lamsft. I i is
2187-A
• ft. ' ft.
NC Well Contractor Ccrtifacadon Number 15.OUTER CASING(for mall eased wells)ORZ ER(if )
Hedden Brothers Well Drilling, Inc i FROM TO { DIAMETER In.
THICIOt SS I MATERIAL
_ ft. i ft.
Company Name q l 16.INNER CASING OR TIMING(geothermal dosed-loop) •
pl D fI
2.Well Construction Permit#:Ad,'41)3 i- 9-/184'7 I FROM I TO DIAMETER I TITIOICRISS MATERIAL
List all applicable well cansrraetion permits(i.e.WC.County.State,Variance,etc) I- 0 ft. I._1/_D it. l0 In. -
v t`
3.Well Use(check well use): t0 ft 1318 it. � 'n' . 188 sr-to L
Water. Weil: 17.SCREEN
Supply • FROM I TO DIAMETER SLOT SIZE TR OO= MATERIAL,
Agin:ulttlydl DMunicipal/Public in ft. in.
Geothermal(Heating/Cooling Supply) EResidential Water Supply(single) ft. 1 ft. I in.
Industrial/Commercial DResidettial Water Supply(shared) is.GROUT
Irrigation • FROM TO I MATERIAL I EIPL4CEMENTMETHOD dr AMOII
Non-Water Supply Well: 0 ft. zo ft I 1.=at I ptanped
Monitoring DRecovery ft. ft.
ajection Well: - - - ft. is. ( -- - -- -
Aquifer Recharge 0 Groundwater Rcmediation
19.SAND/GRAVEL PACK(if aaalieable)
- Storage and Recovery DSaiinityBarrier FROM I TO 1 MATERIAL [ E}IPL►CEMMTMETHOD
Aquifer Test DStotmwater Drainage ft. ft. 1 f ...__
Experimental Technology `Subsidence Control I ft. ft. I
Geothermal(Closed Loop) OTraee' 120.DRILLING LOG(aCaeh additional sheets if necessary)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) FROM I TO I DESCRIPTION[color.)nrinee.soil/reek tvae.train she.etas
f 0 ft. n a f- I Gaya sand
4.Date Well(s)Completed: aJ
8/o2°e?3 Well ID# )8 f` 114OO iL 15rbrae _So.Well Well Location: it. I fn I ` . ; 's—, s ,�
,o‘nn cleka err - I fr. ( f:._I
Fse�llfry/OO/wneNemc /�� FacilityIDd cif applicable) ' j •fr. I fr. l MAR 2 0 2023' :
6)50 ,Sepuk hMnuMtlrx, t.tkIlawka�I 48'-a3 ft. ( ft. ( {���,tt;:,, T Jr.�^.�..A !
Physical Address.City.and Zip ft. ! ft. i. �;i,.�Una:I
J AO.ILSOba Cow Nil - 7543—89-098a4 21.RED1ARKS ,.
County ParealldentificationNo-(PIN) I �` Day tUu2LL -
Sb.Latitude and longitude in degrees/miautesisecoads or decimal degrees: I
Cif well field,one iat/ong is sufficient) 22.Certification:'
,3.5° D9.tDa8 N 083° I I. 091.5 0,,,�-� 8
err a well Pettaaneat or Tem Deer Sigtraturc ofCettificd Weil Contraemr ^'� ` O
6 IS(are)tb (s) p rj
By signing this Iona,'I hereby certify that t swills)was(were)canstrveted in omen
7.1s this a repair to an existing well: DYes or No with 1Sd NCAC 02C.0100 or 11-i NC4C 02C.0200 Well Construction Staniar*and i
If this is a repair,fill out known wrl/eonuructton information &explain Inc naturo of tier ropy of this record liar been provided to the well owner.
repair render 921 remark;section or on the batk of diisfarm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS9.TotaI well depth below land surface: /c 20O Cit.) 24a. For All Wells: Submit this foam within 30 days of completion of.
For multiple wells list all depths ifdlfferent(example-3Qa 200'and 2@I001 construction to the foUo inn:
casing:Static water level below top of )Soo (It.) Division of Water Resources,Information Processing Unit, .
If water leval is ohm casing use" I617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (im.) 34b.For Injection Webs: In addition to sending the form to the address i
12.Well construction:method: `R
n omrt iN „ k above.also sabrat:one copy of this form v-ithin 30 days of completion a` J ) constmerieu to the follouine:
I (i.e.auger,rotary.cable,direct push,ere)
Division of Water Resources,Underground Injection Control Propci"
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636 ...-
13st.Yield(ppm) Method of test: &CUD 24c For Water Sunpiv&Injection Neils: In addition to seadms-therh,
t the address(es) above, also submit one copy of this foray within 30 ch
13b.Disinfection type: r Amount: completion of well construction to the county health department of thee
where constructed.
i
Form G«-1
North Carolina Department t of E-stroamental Q::iit.-Di.sioc.of Water Rssotccrs Revised 2-2
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