GW1-2023-01559_Well Construction - GW1_20230209

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WE�,NSTRUCTION RECO" (GW-1) For Internal Use Only:
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1.Well Contractor Information:
Russell Taylor 14.WATM ZONES
Well COARaRaI Name FROM TO ! ROOM_
V 87-A I to 6is 7 0 N'09 414
ft. H,a''1 ftl-
NC Well Contractor Cettffieitien Number 15.OUTER CASMG or multl•eased weiba PU eabk
Hedden Brothers Well 9rUng, Inc FROM, T9 i i DIAbILTEit RiclCtEss H,►Tl�tut.
Company Name �t ' 66.INNER CASING OR MG Canal doseddoo
I.Well Construction Permit#:g1Q1-,M+8- 9-11,53 --FROM TO i DLLtitETEA TBiC&N-M biATERLIL
an all appflcabie cull ranttructlon permits flu ULC.County.State variance,err- I. ft. 16.1 fa In, PVC-
3.Well Use(check ITCH use): . 45 % I 4.7 fa � � • 188 ,5TEE L e
FIrmrigation
Supply WeIl: 17.SCREEN IFI DI&ME1 SR SLOTSIZE TFIIC[{-7M MATMAL
cultural rIMunicipaUpublic fc ft,I In.
hermal(Iieating/Cooliag Supply) gResidentW Water Supply(single)striaUCommarcial Residential Water Supply(shared) 1&GROUT
FROM I To I MATERIAL i nipLAcLNm-r.%LTHOD&-ZiOCT"r
Non-Water Supply Well: It. .6 IL zacaaec.m I oianped
Monitoring �Rccavery - _ td is
injection Well:
AquiferRechatge �CiroundwatcrRcmediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(I Mal
livable)
DiSalinity Barrier FROM TO; sLstERial. ):vsrG v�MtEaTMLTHOD
AquiferTest OStormwaterDrainage ft. I is I
F%peritncntaI Technology ,' Subsidence Control it• ` tt.
Geothetmial(Closed Loop) D-T-er 20.DRILNGLOG attncbndditlonnlsbeetsifn
Geothermal(Hearin C:ooiin Retum) 0 Other( lain under=21 Recnaen.) vltost 't DESCRIM0%lwlor.Wednea sotVexh n sire eve l
ft. 13 irl I L I clay&sand
4.Date Well(s)Completed: 3A Od 3 Well IDr ' 39 ft. I IiL'
� V I gtatite
5a..�Well Location:
racitiry/owaaNarce �1 Facility MD-(if applicable) 1 fG ft.
a'00 ��rC4WaI1S_ll�lvt�. (.i(llt)l Pe . �`8`7c?� r� rt. I
Physical Address. ity.and 2sp I- R' ft t
Jae"*,s Ceu.,1'f°i
County Pared Idcacification No.1Pl2Ni
5b.Latitude and Iongitude in degreeVialuutesisecoads or decimal degrees:
(if well acid,one iavlong is sufliclaw) 22.Certification.
et ification.
656! 10.005
Signature ofCcnifiedWsll Contractor Dat
fi.is(are)the ne11{s} Permaneat or DTemporat}' I I
-C'► 3y r."grtng rlris Jornr,l Ac A:•crlf6-that xrll(s),cos(We-)wri uttered in asalda,
7.1s this a repair to as esssting well: 13Yes orAcpw'
io a-itlr 1S.4 iYCAC 0W.0100 or IS.4,VCAC 03C.0200 rl'e)t ConsureBon Mandards and 1Jm
ljtlut it a repair fell oat knonzt curl)eorrstruetion tnjornradgn nc�aatura o(zhe copy of thfs recard!ltas been prattded to the ire(!onner.
mpoir rmdir e?1 remtrt iaction or on the back oJthisfamr.
23.Site diagram or additional well details:
S.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 m
consWetion,only 1 OW-1 is needed. Indicate TOTAL NTMIBER of vveIls construction details.You may also attach additional pages if necessary.
drilled-._ I SUBMITTAL INSTRUCTIONS
9.Total well de �5o (ft)
24a. For All tVeIls�.
depth below land surface:
P Submit this fozzt within 30 days of completion of w
For muldpie nvft lat all depila ifddrrml(example-3Qa 200'and 2 100.1 constriction to the following:
10.Static water Ievel below top of casing: 61) (f.) Division of NtTater Resources,Information Processing Unit,
IfivorgrJava[it above Costa&use••=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 2 Cm-) 4b.For laiection Weil s: In addition to sending the form m the address in.
above,also subrait one copy of this forth n3thin 30 daya of acropledon of v
12.Well eonstructiotd method: L h ih� ( L constarctioa to the fallowing:
Ctr-ZUEet,rotary.cable.direct push,etc)
Division of IvaterResources-Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 106 Mill Service Center,Raleigh,NC 27699-1636
I3a-Yield(gpm) +0 Xlethod of test, 24c.For Water Suoniv g Injection Wells: In addition to sending the fors
i(� rite address(cs)i above: also submit one copy of this form mitbin 30 day,
13b.Disinfection type: Amount: conpletion of well,construction to the county health department of the cot
where cottstrac::d.
Form 0%%'-1 North Carolina Department of Environmarnal Qt aiit<-Dicsio.-.os t:'atcr Rcsou:c" Revised 2-21-1•:
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