GW1--08071_Well Construction - GW1_20231215

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• WELL CONSTRUCTION RECORD (GAY-1) ! , • • �:••:
I .ar internal Us Only.
I.Well Coatractnr SufOrmation:
Russell Taylor ; I4.WAnRZONES I
Well Corms Name • I KIM I TO I I I DESCRIPTION
2187-A I I( O II1D51 If" 1 1 g7-doa 093o„2;5
YC Weil Conlr=Caetieati=NNu:aber 160,5 h 16/01 R' 1560-5e
ss.emuTzR cAslTIG(far, meal audwaIIs}a8OCKIKI rigidoLtel
Hedden Brothers Well Drilling, Inc FRost Ta I DMNTtER Ttttctvras atriT!<wt.
CeespanyNcme I I '� In. I
S.wen Construction Permit St dQo�3 aN[a3-9-la71.6 I IL LYNERCASIl�IG OR TUBING DiaG ntstbesta:l das.ddaaao) •
I F7tnat I TO QQ' DLLtiiE[ER l ildATiSEAL
Litt al applicable I Mnstarrettenpaatitt(l e.WC,Cetnuy.State.%dance.ern) I. 0 It. I 7-1 rt. to in. PVC
3.well Use @beck well use); 1A9 it. 143 ft. I 19 in. I • 188 `STEEL
Water Sltpply Welk 17.SCREEN .
• FROM I TO .DIAME SLOT SIZE T 3tA'UiAL
LiMtmicipal/Pubiic ft. IR.; (a.
Geothermal att iS/Ceeding Supply) Resideatial Water Supply(�8lo) ffi fa � ice.
ladviCiiUCoit>$eseia! water Supply(shared) 1g.GROUT I I I
Irrigation • FROM I TO !. I MATERIAL ) nurt. enr1�rMcMi0D.L`A310it
Non-Water Supply well: 10 it I m' it ute,citsr.ft I t
cme
Monitoring EnRscovety ;; ft. I ft
jecoion Weil: I I
i fr. ft
aCfCr Rectiatp DCtmtmdvrztcr Rcmediuioa 19.SAND/GRAVEL PACK dr everteeble)
Storage and Recovery oSaIiaity Barrier FROM I TO I MATERIAL I £1ePLACEMMTMH.TROD
niter Teat DStonsweaterDrainagt ft I x I I
E iperircental Technology DSubsidence Control I I fr. I it F
Geothesmal(Closed Loop)• OTraeer Z0.DR1LI.L'iC-LOG(attach additional sheets if aeeoary)
FROM I TO . I DESCRIPTION talon.tratdae s'Wreakt vans doe.do)
Geothemrmai(HeadaitlCaoling Aeaua) l�iQther(ezalaia wader 221 Rematts7 0 It. I 6_3 r clay a scree
4.Date Well(s)Completed: 1II 13J4'QRi Well Mt 3,5 IL 1860,u- I ra _
5a.Weil Location: r I , IL I �. :.,i' " ,7.,
NC Re 14a1s LI�C - ft ( ft. ; ..;�..,�..�, .-;. v r}j
is ..�
I DEC I
Patdfiq/0wrtalTssae FacliiwIDO{r.'appiieabiei � (e i i � v 7
H,At4,4c,kd. CAs1, 0,87/17 In i ' :t. I ���]
1Pr.S ;r.; rJ,"
Physical Address.Qty.and Zip .1 to ! w L� .;I-.-.;;.-ri i!al
K.SZIO l.rt ILYr� 21.RE rIARiCS ;L1:.7�
Cam Pared Idcatifratioallo.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I .
[if well field,etie.iatlleng is suirteierl 12.Certification;:
,360 Orl. o '1 rf 0836 05.5105 w I ,., JO/4o3
6.Is(are)the trell(s) ermneat or inTemporar} si atuce etCcfied well Can :
����++++++ a pm,
3y signing this Jowl.f hereby thw 1 lal(sl watt pyre)eamtmrd is=an
7.Is this a repair to an existing welt: DYes or „ie,Ili:fox C4C 03C.0100 ar ISA VCSC 02C.OZOD 3Fr1l Cartstrorn'on Standar*and
/this Ise repair,feltat MOM well cacstructian irrfermerianexptair.else cetera elite cop'ofab record has beer:prvvMed to the well otnren
repair rmdfr R31 rrararls station or ce the bad-ofrlarfcan.
13.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may us;the back of this page to provide additional well site details or
canstrmcon,only I GR-1 is needed. Indicate TOTAL.NUMBER of wells � won details. You may also attach additional gages if asecunty.
drilled; I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 85° (ft_) 24n. Fee Ali Wells: Scbazit this forr=within 30 days of completion of
For=Opts warps list aft depths ifdfferrni le=e rlr-3(Qa 200'and 2 1001 cor.stnIction to the following
10.Static water level below top of rasing. (Ft.) Uhlman;cf Water Resource;r Information Processing Unit,
Priam lear(is ahoy rasing.use-=- 1617 Mall Service Center.Raleigh,NC 27699-1617
11.Borehole diameter. 9 (l 1a.) 24b.For In)eation Wells: In addition to sending the farm to the address I
13.Well easstraoaau m-tbad: /La• 1 e r r 1 r1..I., above,also ssbrtft one copy of @his form within 30 days of eoropletloa et
04.auger.town sable.&at post.ere.) w:r t sc�ioa so Lae;feiloccia
I
Division of F'1`arerResources,Underground Injection Control Progra
FOR WATER SUPPLY WELLS ONLY: I 1`636 Mail Service Center,Raleigh,NC 376 6 99-163
13a.Yield Wm) 15 <Iethad of test 6Y64.) j i#c•For`,rater S' oniv as Infection Wells. In adetion to sending the S
(( } I the address(es) there. also submit one copy of this form within 30 d
13b.Disinfection type. 1- Ataounr. L(e I coo:plc-on of well coascut tion to the comity health department of the
where coassticred.
!
Form OW-i North Carolina Dcper:mlac of:o..»�nneic.Q_iiry-Di=so9 of v:accr�nucc.o %wind 2v
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