GW1--03378_Well Construction - GW1_20240610

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WELL CONSTRUCTION RECORD (GW-1) i For Internal Use Only.
I.Well Contactor Information: ,ma •
Russell Taylor i.WATER ZONES
• FROM : TO DESCA :ION
Well Conaaaam,lame 2187-A 85 " ` 9 fL 110- 115
RIO f;. ! Qii ft
NC Weil Conaacmr C Number ! Is.OM ER CASING(for maluwased weds}ORLIN:la(R��11l
Hedden Brothers Well Drilling, Inc FROM ! TO i DIAMETER ! naciere s MATLISAfl
f„ ft In.
Company Name i 16.Si ER CASING OR=BING(aeotharmsl citeaddaoA)
I.we Conmaaica Permit#: 403 01101 {- —9- I5LP 13 1 FROM TO _ 1 DUMMER rat=vass I War
:rss all applicable troll coastrocdan paadss(U.WC,Comity,£amen✓oriasor,eee) 0 ft. ; (�0(� ft. I (p tn. PVC-
.
3.well use(deck wall ass): 64 " I ki 3' ; 6 tan 1 .188 !S,EEL
Water Supply Weal: 17.SCAM'•: FROM TO I DUMEDER SLOT S zc ' THICX2MIS 1 stATsitia
Agsica14tal DMtmicipai/Puoiic , ,,. ft. Lo. 1
Geetbeadai Ciuting/Coolia8 Supply) spResidcntial Water Supply(single) ,_ ft. id.. I ! !
Iadussial/Co eiai DRa de iai Water Supply(shared) ' /8.GRotT
FROM TO m.arraLIL L ETrpLAcnson r MLT80II r A310
Non-Water Supply Well: l 0 ft to ft- ' .....+ mewed
Monitoring OB.' ( ft. ft I)
Jectton I- 1
AttrttrRtc:`a.8a i--Oroundwa:-.keencdizeon
Q 0 19.SAND/GRAVEL PACK Of apiarieablel
i
Storage and R.ecavery Salinity Barrie- 4 FROM ; To StATERLlt. f fmnA,CIEhrtsT stZTf1OD
1:11.guiferTest t 'Sto:atwa o Drainage
ft 1 ft.
�Experir..eata:Technology St:asidea=Control I i it. ft.
OCreothemoal(Q 't:Aop) MTZc: ' 'u.DR .I.iz G LOG(attach additional sheets if ascosar7)
t+� f FRptt Tp , DESCRIPTION(color.tordam.seRindtrn4.gale sue.e
"/GeCthamii alfir nglCaolnsg Reo:ta) r jOthR Ora:lain.tndm=2: arc s) ; E ft. i. `i ft. 1 clay
a sar+o
xt' ,7' �-
4.Date Well(_)Completed:,5/cQ GU/cam/4 well.ID= , DD
set.Wall Location: ' i• /
W1 fit. , Belled.u '~1.��`.i�V LT
eaanisyrowna =acli y MC(i:apat:cal lei t
'1'19 Cox I all it_ ('.0. k Qhee. o?8`1023 ( •
J U N 1 0 x8Z4
Physical Address..arty.and zip ft. t '
A Ad.w aw e�+>• rt o .. , tJ„h
JCICKx)
S0 Lnu,v-ri1 7559- 61._ 8t,oB - si,.Risatwsixs vvVcieL)c
Comity _tcel ideatif=d=No_ 1Nl
5h.Latitude sad Iongitade in degrees/minutes/seconds or decimal degrees:
Owl acid,one 1stlong is sufricicr) 1' Certification:
36° 19. dill 083° 10. 150 w / .•4.effJ _ 5 4
Suture ofCat`,fied Wall Contraro:
6.Is(are)the wef tn
(s) eranent or MTemporary
t'� ;,signing:l:::r/orea..hunk:cer f':real trea(sr was(lrrrl wet nnaec':a ace
I.Is this a repair to an existing well: D Yes orpNo ,•J1:!Li.'PCBC 02C.0100 or!S..1 VC4C 02C.0200 bail Ccits vertar Sradards ex
f repirtr fillop;•of%a rrcc'c ilea been plodded to mire well owaa.
/ibis IS a am know:tKa coaaetsrrlKiian informationGpiGF::fe ra::�r�,`:irc
repair trader 4,11 remarks se tior or an the bad ofrlrsfarce. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells roving the sa..e of may use the back of this page to provide additional well site details
construction,only IIC W-I s needed. Indicate TOTAL NUMBER of wells :onsirtlet ca devils. You may also attach additional paves if necessary.
trilled SUB 1\411 iiAL 1NS':r UCTIONS
9.Tool well depth below land surface: 9(N (ft: 24a. For All Wells: Stbo,the form svithie 30 days of completion
For ma/rrpir xriZr an all depths i'fdifferear resa j!r-36200'a'Ri 2C4/001 conasceCon co;ha followin=
casing:10.Static Tracer level below top of sing: J4 (ft.) Dilston of Water Resources,Information Processing Unit,
avatar laud it abota•c atg.tar.. " 1617 MIaIl Service Center,Raleigh,NC 17699-1617
11.Eorahole Mau:seter: L9 vL-: 16b.For laiecdon Wells: In addition to sending the for a to the addt, t above,also sobr t:oar copy of Cain form whilin 30 days of completion
12..Well conviction n merbod: S.Jt.et it. ..0.1 constrnclion to the follomia
Clan auger:totsi7,mirk,Greet push.etc.)
Division.of Water Resources,Underground Injection Control Pros
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
I� �v+r:�D i 24e..=or Nearer Sueoty.P.;Inieerion\Vei11: 3 adaion to sendmn the
Sae.Yldd 1:ettcd o:test
es
(gpm)
` t the address(m) above. also submit one copy of this fame within 30
1.3b.Distafec oat type; �i t K yaocn:: a �?-, _1 atmpiadaa of well nowt-notion to the county health depot tees of it
v amen e9as
Poem ow.; may:.;z.-n::-:.Jt--r.-_-:o'fi- aao.a1:i Q"21%K.hishile o:theme,RasaYsces R;Tiied.