GW1-2023-02663_Well Construction - GW1_20230411

• LL CONSTRUCTION RECORD GW.1
For Tatemal Use Only
1-Well Contractor information:
Russell Taylor
wall ContreowNeme I4.W ERZONFS
2167-A opt To ' i i usscluPnon
It
KC WCH Contractor Cron Numb, 7 ft. 7�Q
Haddon Brothers Well Drilling inc ormolu=edwelts oRDnvERflt le r Fttolt TO i MA1tti:TEit ry;
CotapaayNmee _ iL ft in. K TZMAL
2.Well Coastmadon Permim- 16 LNAZRCAEN DRTtTBlKG erraalaloseddoo
Un a1l dMilw6k ttd l ca F C TROSI To , auat>:1 ER 7}IItS{:1lEss 1KA tsrurrerton ramfta a NG C"trnry,S
tat
e
Yariarue,err.J la.
3-Well use(check won use): I tL 1 SL, V�
Water Supply Weil: _ �a I p rL m• 8 E�,
17.SCREEN
Agricultural E2MnaicipaMblic °(`t To m.►utezEtt st orstztt rlffctc� atATl:ltllaL
Cteotlsesosei Mcatting)Coolftt S tL fr. Ia.
al
6 uPP1Y) �Resideatial Water Supply(single) � :tL is IndustriaVCommaeial Residential Water Supply(shared)
hti Lion I8 GRDtIT
IQ4t,_W, ter$ FROM TO }tp� L Eatpt dGlwli�lTaTEfHOD 3 L�1CIG1 Dpn�r well: tL Zo �.
Monitoring �a�� Pumped
ection Ye)l; Recovery fL ft-
Aqui&rRcchatgc �Gtouadurtcr Rcmediadon fL I :L
Aquifer Storage and Recovery 0,SalWty Battier i9.SANDlGRAStEL PACK If a liesble)
FR0.4f TO ]L1T6nLlL FatpLAGE1tfE�ThtEniQD qW*r Test Stormrrsta Drainage ft. I fc
Experimental Technolory Subsidence Control ft. I n
Geothetmal(ClosedLoop) �'fracer zo.nRILLI:VI 6L0G atWchadditiooaIsheetsiin
CleotIteratat(Hearin Coolie Realm) Other(ex lain under g21 Xemarls) moat •to DESCRIPTION(color.h2rdaemnithaek a >da eeas
� ft, fL clay d sand
4.Date Well(s)Completed:s? Well M# tt. 8 ft. I yran�
Sa.Well Location: -
NNJ�h, 0✓TiSCtk ft. ft.
,,.Faculty woe VPtm .� ') Facility M6(if applicable) fr. R. l j zon
�a- ► im r 'wrlo r° sL
Physfeal Address.City.and Zip � I sc-1 ft
� f �CiiGi n tilt:
-6o 5.00953308
County '.1.R£SL4IiICS -
Pared Ideatiheatioa No.(PLC) �
5b.Latitude and Ioagit udc in degrees/minutes/seconds or decimal degrees: I
(ifweU field,one iatilong is sufficient) 22.Certification:
35• rid.01,8�,(8 .� ®�3°aAl-.a;33 W 3�acne 3
6.WIN the aell(s) Permanent or rtiTemporary SignatureofCett(fiadNollContmetor Date! I
't� Bp tigeriag this Jana!hereLv certify that r urll fs)ices h�rir)coastraued in azardar
7.Is this a repair to an existing[veil: E2Yas or No aide 15A NCAC 03C.t))00 or ISjt VCBC 0?C.OZ00 IG'ell Canmsrctlon Sand n*and ilia
#*this&a repair•Jill out kaown 1-11 eonstr•uetion tnfarmarton -esplair rhr ratur..of the cope gfthb retard has been ptasided io the well oimer.
repair tmdir gull remorltr jawlan or an the back ofi tisform.
?a-.Site diagram of additional Ivell details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or w
corimcdon,only,I OW-1 is needed. Indicate TOTAL Ni MBER of Nvells construction details[You may also attach additional pages if necessary.
ceded:.— Q SUBMITTAL INSTRUCITONS
9.Total well depth below land surface. V CfL) 242. For All wens: Submit this f031 within 30 days of completion of v
For malnpte urltc 1W all depth lydolermt(vramp1r-3@200 and 2@1001) construction to the following
10.Static water level balon•top of casing: 3Jro (fr.) Division of F4ater Resources,Information Processing unit,{J,vafrrlauvllrahovr cmirt�rsv �^ I617.Nlail Service Center,Raleigh,'14C 27699-1617
11.Borehole dfamater. (ta) 24b.Fe r In ieetion`Wells: In addition to sending the form to the address in:
L• above,also submit;one copy of this form within 30 daya of completion of c
12.Well,construction method: 41 consttuetioa to the feiloniae:
G e auger;mtaty,cable,direct ptsh,etc)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service
Center, aleigb,titC 27699 1636
13a.Yield(gpm) 0(gq0 rNlethnd of test: 1.4c.For Water SunnTv&Infection Wells: In addition w sending the fora
the addresses) above,I also submit one copy of this iban within 30 day:
13b.Disinfection type: rl Amounr: ` completion of well construction to the county health department of the coi
where constructed.
Form 01'-1 :_
North Carolina Depar.;renr afE-.simntacn;al Qyalit±-Di�:�-io.:o:t�It-rvRcsou:ces Rori,ed 2.13=