GW1--04498_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.wan ZONES
- i PROM 1 TO ,1 DESCRIPTION
Well __2187-A Na>� ' /103 re' 11(08 f`I I?aD-405
•
YC Well Cana-actor Certification Number del ft. a/dzFLI15.OUTER CASU G(for maltkased wells)ORLINER Of aRtneobit) •
Hedden Brothers Well Drilling, Inc I FROM TO I ! DIAMETER I THICIVESS MATERIAL
ft. f. In. 1
Company Name qwn n 16.DINER CASING OR TUBING(geothermal elosed•(ooP) •
2.Well Coastruedon Permit#: aoa.3-.24345-R- la?G/µ I FROM 1 TO DIAMETER 1 TfICINEss MATERIAL
List all applicable trail canstruallan permit:(t.a.WC.Comm.State.Varial;e4 etc.) . 0 n' I 81 fz t tn. PYG
3.Well Use(sheds well use): i RI m 18 zo ID in' I . 188 .5 rE EL e
WaterWell: 17.SCREEN
Supply FROM I TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Ag ieutntral uMunicipal/Public ft. ft. in. 1
Geothermal(Heating/Cooling Supply) EResidexuial Water Supply(single) to it: I in.
InduasialiCommeseial DResidearial Water Supply(shared) is.GROUT
Irrigation • FROM I TO I MATERLU. 1 ntPLAC tm-r3FEIRODfi,l110Q,17
Non--Water Supply Well: 0 ft. ! as it. I ...a.rseora I owned
Monitoring OReeovery !I
I fr.ffr. I ft.
fection Well: , I f;, II
AquiferRoclmrgc DGroundwztcr Rcmediation
19.SAND/GRAVEL PACK(if aepUtcable)
' Storage and Recovery DSa1inity Barrier FROM I TO I MATERLtl. EITPLACCMMT METHOD
Aquifer Test MStormwater Drainage ft f ft.
Experimental Technology 0Subsideace Control I fr. I f. I
Geothermal(Closed Loop) Tracer 10.DRILLEIG LOG(attach additional sheets if aecararv)
FROM TO I DESC RO TION melon hanthees.soBhxt t sa!nth=a.ethf
Geothermal(Heacntr/Cooliag Rcarm) Other(explain under Zl Remarlsl 0 fr. i IN' ft. slay E.sand
4.Date Wells)Completed: L &47fa20d3 WeliID# i 74. it: I 5DO ft' 1 granite '
r
fr. rft. I. . .�.r^ . "-• "
5a.Welt Location: b a .
LJOCNn+sia�sblkfip+ts� !.L•C rr. ft.rses7iq/owaar(llTame FacilityIDd(ifapptieaaalc) I !U I 1t. 2021
re_ I is
181 US (oil w . Ca.�li�icS 08191? I re_t. ft. • .,... ....:, .,.............,..,,?,.1) I
Physical Adders city.and Zip i ! '' ( r S
tJACKS°t.3 Coairty 157a-3►-IA?1 ' 31.REMARKS
Camay Parcel ldcadfreadan No.(?1)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
[Livid geld,one lat/ioog is sufficient) 12.Cerdf cation:
35e Ole.1,99 N 683° Um.a21).3 w /?,..47 .4.&023 gir2422a
6.Is(are)die well(s) Permanent or Temporary
Sigsaturc ofCmtifcdWell Contractor
dy signing:kis form.1 herein,-certify that r•wars)max(were)eoasa'aeted in accords
7.15 this a repay to an existing well: r Yes or No whir Ili NCriC 03C.0100 ar IS.4 VCr4C 02C.0200 Well Cot:Metdan Sandardr cad d,
If air tr a repair,fill out know:writ cwatruction irrfarma:ion chaplain the nature of du- copy of this weird litre kern providrd ro the null owner•
repair:mar tr21 remark:section or at the bad.of this form. 23.Sire diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells staving the same You may use the beak of this page to provide additionsl well site details Cr'
construction,only I GR-1 is needed. Indicate TOTAL NUMBER of wells cansuuedon details. You may also attach additional pages if necessary.
drilled: I ^^^^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t3DC) (ft) 24a. For All Wells: Submit this form within 30 days of completion of
For tnaltiplr wear Ito all depths ifdiffemrt tesamplr-3(§200'aid 2(0100'1 construction to the following:
10.Static water level below top of casing: 15 (ft) Division of Water Resources,Information Processing Unit,
Ogler level it above casing.use"-" 1617 Main Service Center,Raleigh,NC 276994 617
11.Borehole diameter: LO (tn.) 24b. For Iniecrion Wells: In addition to sending the form to the address is
li 7 -� abeve.also sr3ret one copy of this form-within 30 days of completion of
1Z.Well construction method:_ ��L• !�J�C f��.t'�l construcciaa ro the faitocria
Nis.auger,mea(y,cable.diesel pugs.era)
{ Division of Water Resources,Underground Injection Control Prograt
FOR WATER SUPPLY�1/WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm} '4.0 Method of test: ai A j r,c•For Water SunoIv&Infection Wells: le addition to=dig the fo
the address(es) above. also submit one copy of this form within 30 da
13b.Disinfection type: I.mount: [e completion'of well construction to the county health department of the e
v where constructed.
Form Cr1V.1 Nord:Caroline De7ar..rt^1C ofE.-sraa.:.a,;z Q_iin•-Oi•-ision of t`:a.or It.zoa:c.-s
Reesised 2-2.'