GW1--04497_Well Construction - GW1_20230713

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. WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only.
1.Well Contractor Information: •
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Russell Taylor I4.4frATERzolQES
I FROM I TO I I DESCRIFf1ON
Well CttatraetorNsn�2187-A &2 I g fL 131 fL'I µ7-6a
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NC Well Contractor Certification Number j&I ft. 55 ft.'I 65-60
. 15.OUTER CASING ffor malt erred wells)ORLINER 0fappilnbkl •
Redden Brothers Well Drifting, Inc ! FROM TO DIAMETER I T/IICIKYQS MATERIAL
- f'. ft. tn.
Company Name 1 IL LINER CASING OR TUBING(geothermal c neddaota) -
Z.Well Construction Permit#: 02/3a1- )FR- q- Ir2 5j.7 I FROM I TO DIAMETER TarMISS MAMMAL
List all appaeablr WE tanstructfon parnirs(i.e.WC.County,State,Nrariai ce,etc) 1- 0 tti 1 30 ft. to. PVC
3.Well Use(check well use): 13O ft. I So/ ft. ra •158 5E EL
Water Supply Well:
7.7.SCREEN
• FROM I TO DIAMETER SLOT SIZE TFIICTODDiS MATERIAL
Agsieuleisal Li—Municipal/Public ft. I ft. t in.
Geothermal aleasittg✓Cooling Supply) mItesidential Water Supply(single) ft. ft. { in.
Industrial/Commercial DResidential Water Supply(shared) is.GROLtT •
Irritation • FROM I TO I MATERIAL EMPLAczgoiTMETHOD.0AMOI.Orl
Non-Water Supply Well: D ft- za ft- eecar_se a.e I teamed
Moaito:ing ORacovery ! ft. I O.
jectfon!Yell;
I 2:. i ft. �
Aquifer Recharge D Groundwater Retncdiadon
19.SAND/GRAVEL PACK Of=rat mble)
Storage and Recovery Salinity Ranier FROM I TO I MATERIAL I EMPLACEMEM METHOD
uiferTest OStaratwaterDrainagc fa I ft.
Experimental Technology• 0 Subsidence Control I ft. I ft. I
Geothermal(Closed Loop) E3Traeer 20.DRILLING LOG(attach addition's/nets if occ sari)
FROM I To r0 I DESCRIPTION levier.tmMem.seRteek net.eratesit&etc.)
Geothermal(Fleeting/Cooling Return) nOther(explain under;=21 Remarks) a fL I n
clay 5sand
4.Date Well(s)Completed: L��a9 --,, K.3 Well> o2.2.tL fL 130o I gratis
5a.Wall Location: I ft. I It. ,—
^
,Facility/OwnerNamme Facility ID (if applicable] i fft. 1 ft.
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Lot a2a Valley f2d . Cas�ie s i c 28'717 D. i ft. JUL i ZUZ3
Physical Addicts.City.and Zip ft. I ft. t Ines -r-_i..-, P.....;-. i.;i .i
(-ou iN V7 5J' 7 J-18-(0935 21.REMARKS 4.. ..•
County Parcel identifrcatina No.(PLC)
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
lif well field am isvloeg is sufficient) 23.Certification:
S6° C.385 N b83° 05 897 4�
z_ .,./.6' &2,5._
6.Is(are)thewell(s}Permanent or aretnporary
Sigmtorc ofCenifted Well Cr '^
dy signing this forma I hereby cerfifp that 1•str11(s)uta(erre)oo um:aged kr meant
7.1s this a repair to an existing well: ElYes or liNo w rir 15r1 .Cr C 02C.0l00 or IS.4 VCAC 03C.Q200 Well Cotstrrretlon Sandmels and if
If chit it a repair,ftI1 out know;writ construction information dcpieir:the natter of t/rr copy of this record has beer.Pollard to the well owner.
repair ender i'21 retiree#seceiorr or on the beck oftlesfarm. 23.Site diagram or additional well details:
S.For Geoprobs/DPT or Closed-Loop Geothermal Wells haviae the same You may use the back of this gage to provide additional well site derails or
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construction,only I OW-I is needed_ Indicate TOTAL NUMBER of wells :commotion details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�"//y�tam� (ft.) 24a. For ANl Wells: Submit this forest within 30 days of completion of
Far medtipte:Wig list all depths ifd/ffrrent(rsanplr-3(§200'end2V001 construction to the following:
10.Static water level below top of casing: /0 (ft.) Division of Water Resources,Information Processing Unit,
limier level is ahem.=shw.tar--." 1617 Mail Service Center,Raleigh,NC 27699-I 617
11.Earettale d[atsserer: i<3 (tn) 24b.For Iniection Welts:. In addition to sending the form to the address it
above.also submit one copy of this Some within 30 days of completion of
12.Well construction method: it1�+/�Q(,1 construction to the following:
(ss•auger.mtery,able,Covet push.=.)
Division of Water Resources,Underground Injection Control Prograt
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FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a-Yield(gpm) 50 Method of tesn EieriAD 1 2 c.For Water'Simply Sr Iniection Wells: ID addition to sending the fo
t (s the addresses) above. also submit one copy of this form within 30 der
lab.Disinfection type: �j'S am l �Q ount: 'I completion of Well commotion to the county health department of the c
(.. where constructed.
Form OW-1 Revised 2-I
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Void:Carolina Depar.�^rt of S.-Aranr..:n;i Q-�iE:y-Di v'sio:err C:trier R�om:c�
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