GW1-2023-01514_Well Construction - GW1_20230209

• -•:_--Priflt�F
WELL CONSTRUCTION RECORD (G%1) For Intemal Use Only:
1.Well Contractor Information; l
Russell Taylor 1 14.WAT&BZONES 1
FROM TO I i DESCRIPTION
Well Cam c:orName i� ft• I 93— 8
2187-A ,
NC Well Contractor Cation Numbs
11S.dtJTEFt CASIlVG for melee-ez+ad Wells 08L1TIER(!4 I
Hedden Brothers Well Drilling, InG FRoaI Tar D1,01 rm THICICaM blATtRuu.
Company Name 1 A�J n 16.INNER CASING OR TUBING ermai dosed-lao
1.Well Cetlsiaacdon POrtalt r: oq®°`!i CXcal F' FROaf Ta I a11,513tBR 7x1t;TL M DIATSM&
Litt all ap#1wble rlrll mau ruc9an permits(,a WC,Cotenty,State Variance,etc.) !a- . 188
3.Well Use(checkwcll use);
[Industriol/Commercial
CRM
Supply WeII: FRo4II o I DWIEM sLOTSIZE TMCFLOMS E]MtmicipaUPublia ft. ft.I in.
hermal(deatirT/Cooliag Supply) Residential Water Supply(single) it in.� esideatial Water Supply(shared) M GROUT
t(aa11FROM I TO I I E1iPL4CE1M73FETH0DSA)t01T
Non-Water Supply Well: IL 20 lZ a�emh evYso I oumvad
Monitoring Recovery -- IL IL
lGeothermal
ection!Yell: It. i ft. I
quifcrRcchargc OCimundwatcrRcmediation 19.SANDlt=RAVELPACK ifs livable)
quifer Storage and Recovery DISaiinityBarrier FRa�I TO .LtTERLiI. i:.rPLlteta+s�T3IETHoa
quifer Test �Stormwater Drainage is. i tic
xperimental Technology Subsidence Control l fr. +tt
eothermal(Closed Loop) 0-Traeer 20.DRILLLIGLOG attachaddidoaslabeetstfn
(Heatin Conlin Retum) Mother(explain under--21Rcraarls) FROM I Ta' DFSCRIPT10%1color.hardne sunlroc@Raavratn Sim eml
I ® : I clay b sand
4.Date Well(s)Completed:�� Well ID# i qo
iL I C)o �is I gran to
Sir.Well Location:
t s Cc�Iut, pecan ft. lti j 4 K'ft. `I
,��.,
FacilitylOwacrNstao Faalffw ID�(ifappliaable) fa ft.� ti �y'6 }
B
r. ij
Physical Address.City,and Zip
°I REMARKS i
County Porcci Identification'NO.(PLC) e
Sb.Latitude and Iongitude in degreeslsainuteslseconds or decimal degrees: 1
(ifwell 64d,one lavlong is sufficient) U.Certificatiar}:
,35° Qr7.5r7t, a 830 )3. D 43 W AAr jq a2oa
6.ls(are)thewell(s) Permanent or OTemparauy
Signatum ofCcn(ficd'%Vcil Conuacwr D
By s.string this Joan,I herein eertijy-rhal , rreff(s)was hrem)roamucted in accordm
7.Is this a repair to an esfstiag well: [3Yes or Va t+t-tie 11-1 NCFC 02C.0100 or IS.d,VCAC 02C.0200 five!!Consatedon 9andardr and dm
If!leis fs a repair jd1 out[sector+ve/1 eoreseruetlon injorprotion eZesplain the aatecr ajthc• copy of this record leas been provided to the mll ouster.
repair under 921 remark ser i:=or on the boar ofiftirjarm. 23.Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or e
conshuction,only I OW-1 is needed. Indicate TOTAL NTLUBER of%veils cotlscrucdon detatis.,You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCI'IOA'S
9.Total well depth below land surface: � (ft-) 24a. For All *eIIst `Submit this form within 30 days of completion of t+
For malelplrwel&tat all depths ifdifferent(esmrplr-3@200-and 2@100.1 Constrretioato the fonowing:
10.Static water level below top of casing: (ft) Division of W-ater Resources,Information Processing Unit,
y1mter lave!is above cashes,uw- I617'Man Service Center,Raleigh,NC 17699-I617
11.Borehole diumeter: 0 (1m) 24b.For iniection iWPH17: In addition to sending the form to the addrm in.
h f y'�''�� above,also submit lone copy of this form mithin 30 days of completion of e
12.Well construction method: L w"-` construction to.ihe followine_:
ox.auger,rotary,able,direct push,etc.)
Division ofiWaterResources,Underground Injection Control Program
FOR WATER SUPPLY WELLS GINLY: 1636IMail Senvice Center,Raleigh.VC 2769 9-1 63 6
13a.Yield(gpm) C ® 13ethod of test_ 24c.For'%Vnt�r Sunoly g Injection wells: In addition to sending tho fors
_ the address(cs) above. also submit one copy of this form within 30 day!
13b.Disiafegdon type: Amount. completion of swell construction to the county health department of the cot
where eonsntrcted.
Form ONV-1 North Carolina Depatrrcnt of E--+iranm.ntat DMS.ior.o-'%"aEcr%csou=cs Reused 2^'=':
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