GW1--04496_Well Construction - GW1_20230713

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. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ! • '
Russell Taylor i 14.WATER ZONES ,
• FROM I` TO I DESCRIPTION
Well Common Name
2187-A 58 I 63
• r1 r1
Nc Wcll Comae c tit Catt rims Nonzber N
1S.OVIERCASIZSG(for mold-eased wells)ORLIlVF.R( •
Hedden Brothers Well Drilling, Inc ! FROM TO I DIAMETER I Tf1It:COES5 1 MATERLIL
ft. ft. in.
Company Name /A�^n /n 11// l I6.Ii NER CASING OR TUBING(geothermal eicdamD} •
I.Well Coastrucdon Permit#: ofO3"eQ/46'T'7'9-, in 97,5 I FROM I TO DIAMETER l TRIM= MATERIAL
LW all applicable well cerssatteCon peraritS(La.WC.County.Stare.Variance,etc) • 0 R 15 3 ft toIn. ' , p Ye,
3.Well Use(cheek well use): i 63 16 5 fn I to .188 STEEL. '
Water 17.SCREEN
�pplY Well: FROM I TO DIAMETER SLOT SIZE THICK MATERIAL
Agtiealttrral DMuaicipal/Public ft. ( ft. I in.
Geothermal(Heating/Cooling Supply) 5§Residenttal Water Supply(single) ft. I it: I in. ,
Industrial/Commercial D.Resideatial Water Supply(stated) is.GRotn'
Irrigation • FROM TO i MATERIAL I EMPLACEMENT EMPLACDLENT METHOD&A.N a
Non-Water Supply Well: 1 0 ft za ft I �_�. p1 aced
Monitoring ElRocovery ft. ft. .
jeetion Well: f;. ft.
Aquifer Recharge 0 Crtoundw2tcr Rcmediztion
19.SA.ND/GRAVEL PACK(if apafteable'
Storage and Recovery Em.Salinity Barrier FROM I To I SIATERLU. - 1 ntrLACEM TMErHOD
WIT Test EDStormraterDrainage ft. ft. 1 I
Eaperiaaeatal Technology OSubsidence Control f fr. ft. I
Geothermal(Closed Loop) OTracer 29.DRILI.LNG LOG{attach additional sheets if nehvars')
OM I To I DESSCRIPTIONtensor.Iasdneasoll/kaeltt t aleflm'etz.l
Geothermal(Heatiap/Cooling Return) other(explain under=2 FR
rk 1 Remas) fr. I 14,5 ft. I
Gaya sand
4.Data Well(s)Completed; iiifir2423 Well ID# iI45
fr. e00'f:. �,
Sa..r Well Location: ft. I 'I , rt.M OAK° 14,..Vr ift. i(�• .. 'a.?.a r. ,
as icy/Ownm'sent Facility ID. ft. ft.cifapplicable) I
441 Fete_si S`eAt.t. -i i i Cu lied Aker l .413 7.23 '
Physical Address.City.and Zip •
JfaCrt.San I it. I- ft.
�1 "36-1 C.?7 21.REMARKS Ira:Ci e.•a-"'Sl s C`i•'_'.:- • �:c' L}t jl. -
4our•f?� 7��OS a C.;•'�:,nC.IG
County - Parcel Identification No.(PM l
Sb.Latitude and kingittade in degrees/lainuseslseeoads or decimal degrees:
Iifwell field,one let/long is sufficient), 22.Certification:' - -
35° n8.914 N 08.3° 08.4 Pi w a..t-
6.Is(a IS(are)the well(s} Permanent or Temporary
Sigrztota of Centilled Well Contractor
3y signing this forts.I herebycrri Mat t•well(s)was(Were)eoartrsaed ire acorn
7.Is this a repair to an existing well: DYes or No brute IS.i:NCGIC 02C.0100 err 1S.-1 VC- SC 02C.0200 Well Construction n dar&and t
If tltir ire rtpeir,fdl out known well eonstraatian iaformatiaa chaplain the ratrr2 of Mc copy of this rrcard haw been pr a idrd to the well owner.
repair mrdvr 021 remark;section orca the back aphis farm. ::3,Site diagram or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the sane ou may use the back of this pace to provide additional well site details or
construction,only Il GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also Mtseb additional pages if necessary.drilled: SUBMITTAL INSTRUCTIONS
9.TotaI Iva depth below land surface: 9 00 at-) 24a. For Ali Welly Submit this form within 30 days of completion of
Far multi*;sl tistalldepthsiFdrffirenticsamplr3Q300•and2(g)1001 ro o-actiontothefollowinz -,
10.Static water level below top of rasing: 6 3 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level it above carom use ='• i617 Mail Service Center,Rale;h,NC I7699-1617 . _
11.Eorehole dtaareter: (..Q am) 24D. For Infection Wells:. In addition to sending the form to the address i
C „t above.also submit one copy of this form within 30 days of completion o:
12.Well saastraeIIari method: +l • f� tJ�C L construction to the folloteine:
Crs auger,mesh',cable.:an=push.etc)
Division of Water Resources,Underground Injection Control Progra
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh.NC Z7699-1636
331i.Yield(gp>a) 5 :1-lethad of test 6.0643 'f'c-For Water Sttnph S Iniecraon Wells: 1a addition to sending the.h
I+ I the address(es);above. also submit one copy of this fora within 30 d;
13b.Disinfection type. Amount: l Le 0 ` 4 completion of well construction to the county health department of the t
G where consttuotadi _
Form OW-1 North Caroline Deparvro^tt of Ensroa-:ntoi Q_it -Di is:on Of'.ad.r a.mourc� . Revised 1-I