GW1-2021-00822_Well Construction - GW1_20210215

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WELL CONSTRUCTION RECORD (GW-1) For Informal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Wdl Contractor Nanla FROM TO DF CRIMON
2187-A rJO R.
H. ft.
SC Wd l Connector Certification Number 15.OUTER CASING for could-cued wells OR LINER(if livable)
Hedden Brothers Well Drilling, Inc FROST TO QAT IMIEB THICICVESa 1AT1RJA[.
R. rt. in.
Company Name
16.INNER CASING OR TUBING hatathermaJ closed-too
2.Well Construction Permit p: MoM I TO DIAMETER THICKNESS AIATERIwL
Lnr all uPPllrahle aell ronrtnmtion permits(.e.UIC,Cnwrly,Stale, Y tartar,ew) Q R. ft. '" 0• T£E L
3.Well Use(check well use): f. ft.
Water Supply Well: 17.SCREEN
FRONT TO WkIlETER SLo'rsl>.E TFIICKNESS eIATERI.\I.
Agricultural MunicipaVPublic
Geothermal(Heating/Cooling Supplv) Residential Water Supply(single) R. R, in.
IndustriaVCornmercial ®Residential Water Supply(shared)
18.GROUT
Irri ation FRONT TO .MATERIAL EJIPLACEMEST.NIETHOD B ANIOURT
Non-Water Supply Well: O fI. R. pumped
Monitoring 13Rccovery n. n.
Injection 1Ve11:
A ui fer Recharge ft. ft.
9 g ©Groundwater Rcmediation 19.SAND/GRAVEL PACK Ba pliable)
Aquifer Storage and Recovery QSahniry Barrier FRONT TO MATERIAL ENIPLACEDIENT NIETHOO
Aquifer Test [3Stomiwater Drainage ft. ft-
Experimental Technology OSuhsidence Control fr. R.
Geothermal(Closed Loop
Tracer 20.DRILLING LOG attach additions]sheet,If eecessa ryl
FROST 10 DESCRIPTION color.hardness,worock n e, .in si-.amu
Geothermal(Heatine/Cooline Return) -0ther(ex lain under 721 Remarks) R f l�r ft
'f ctay a sand
4.Date Well(s)Completed: L Well ID" ft j000 ft' 'tame
5a.Well Location: n. ft.
H lT io''' HaYllfwl gesoy-t LX. ft. n. j
I'm ly was Nr� Facility lD.tifapplicoblel ft. ft.
G Elwsinn4L C hie, QRr7In ft. ft.
RAddress.City, ALJ,p ft. ft
J uyzorl (s,��y� s'15p ) -O5 _L�.r'I CIO 21.RE\LARKS
County `Aa Parlcell hit,nuticalion No.IPIN1
51a.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ifwdl field,one lot too,is suiticienO 22.Certification:
-350 01n. o5L4- N DR? ' Oy .'F90 W lfa I I &oar
6.Is(are)the well(s) Permanent or [3Temporary Srgsaurc at Cenificd Well Contricmr Datc
dy signing'hisform, 1 herrbr cerah that vellpl cons(ore)consrmard in accordance
7.Is this a repair to an existing well: RYea orfie
No q uiyi'13A NCAC 02C.0100 or l5.4 NCAC 02C.0206 lVell Consi mcnan Standards cord ilia/a
/frhu o a repair,Fll out kmm�r will cmutructian irrfornainoo r explain die nrrr)ge Ytlr© f-�l's'Irhir rerord has been prariArd ro the rrcll m,ner.
repair under R'2l rnvarks section or on rice bad of tiro jam:. ,-_V 'A
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER d(wells construction details. You may also attach additional pages if necessary.
drilled I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: low (ft.) 24e, For All Wells: Submit this form within 30 days of completion of well
For nrahiple rrellr fal all depr)u it dol,,nt resanrple-3lg)200'a,,d 2Qn 100) construction to The following:
10.Static water level below top of casing: (f.) Division of Water Resources,Information Processing Unit,
I/r,arer level,,ahowe rasing:u,"-" 1617 Mail Service Center,Raleigh,NC 2 76 9 9-1 61 7
11.Bo reItale diameter: _(in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fool within 30 days of completion of well
12.Well construction method: .Lh '(,��rv� construction to the followine:
p.a.auger,mory,cable,direct push,eu.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q �,.,, 1636 Nail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �A Method of test: U^r.)kw-/ 24c. For Rater Sunohv S Iniection Wells: In addition to sending the form to
the address(es) above, also submit one cop% of this form within 30 days of
13b.Disinfection type: `` Amount: completion of well construction to the county health department of the county
where cansmmted.
Form?GW-I Nomb Carolina Depanment of Environn:em^I Q=11m.Diekion of/Parer Rscures Rsced'-22±01F