GW1-2021-00823_Well Construction - GW1_20210215

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Print Form
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Wcll Contractor Name FROM TO DESCRIPTION
2187-A I-Z+ ft.
n
NC Wcll Contractor Ccnification Number
I I d rt. 1 rt.
I S.OUTER CASING Ifor multl-used weW)OR LINER flf Iicable)
Meriden Brothers Well Drilling, Inc FRU.M TU DIAalETE0. TRICKVESS atATERIAL
n.
Company Name
lb.INNER CASING OR TOBING mthermal timed-too
2.Well Construction Permit#: FROM To DIAaETER THICKNES/S� PIATERIAL
btrt all applicable well construction pei mil,in r.WC,Com.ly,State, Varim.ce,etc) ® it. /-`7 fL In. oe ate/ STEEL-
3.Well Use(check well use): ft (Y I ft. in.
FGeotheimai(Hemin
Supply Well: 17.SCREEN
FltOM TO DIAMETER SLn I'SIZE THICKNESS MATERIAL
ultural Munici al/Publi<
P (t. ft. in.
hermal(Heating/Cooling Supply) Residential Water Supply(Single) ft ft ip
triabConunercial Residential Water Supply(shared) I.SM" ..L
GROUT
ation MATMAL EPIPLACENEN'TMETHOD 3 AMOVNT
ater Supply Well: ,,,,,, pumped
itoring Recov ton\Yell:ter Rcchar c .g [DGroundwatcr RemedialionCK if. licablelfer Storage and Recovery Salinity Barrier NIATERIAL ENIP"CEITENTMETHOD
fer Test QStomtwater Drainage trimental Technology' Subsidence Control t.
hermal(Closed Loop) !Tracer 20.DRILLING LOG(attach additional sheens if necessa )
FROM '1"O DESCRIPTION Icolor,aamnev..oiVrocVn e, net hermal(Hearin Coolin Return) -lain under d21 Remarks) () fa 2 n
day a sate
d.Date Well(s)Completed: I i8 DR Well ID'—' &,A ft- 1000 ft. , granue
15a.Well Location: r� It' I It
H NAmoToo R P.de4T LL C, It. ft.
DIS
Facility/Owner Name Facihry ID-(ii applicablcl ft. ft.
Mi1rF_i,7 LAIJL /1 ft. n.
( pyF11ER5, as�(7
Physical �
Address,//Or,and Zip ft.
p n. ft.
JAU-Svi l-OUPUT'4 r1 5 11—Av'593O 2L REMARKS
County Parcel Identification No.(PIN) F
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
i:fwcll ficid,one IaViong is sufficient) 22.Certification:
350 OLV- 085 N 08,56 DIED. oaa W
6.Is(are)the well(s)pA permanent or C3Temporary Signature of Cenified Well Contracror Dat
TTT B) signing dais(arm, f hereby rem/i +bar , ,cell/.:) vm�pm e)mnnrunrd in accordaner
7.is this a repair to an existing well ©Yes or No „ilh l5d NCAC 02C,0100 or l5d NCAC 02C.0200 IVell Conslrumioo standards mid ihal a
///r/rir isa rrpair,allow Rnpwa.vrll cmvrn¢lion in/orrnalion r rrplain thr nature h.. \opo afthis.cold has been procidM ro thew/!a,,,er.
repmr under d2f rrnam k,section or m,the bad-p0hh facb. ra
r `LU a 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having thgg�salipe You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBERo(ulls construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
o..rudrmle well.,lot all deplh.,it dilT rn,r...ample.3.@a200 andd�2 erylp0•) oanstrueGon to the following:
10.Static water level below tap of casing: ICJ (ft) Division of Water Resources,Information Processing Unit,
lri'dter(goal is ahmr raring....." 1617\fail Service Center,Raleigh,NC 2 76 99-1 61 7
11.Borehole diameter: _(in.) 24h. For In i ection Wells: In addition to sending the form to the address in 24a
��ly ^ 'ahoce, also submit one copy of this form at thin 30 days of completion of well
12.Well construction method: 0 LJ construction to the following:
(re.auger,'inarc.cable,direct push,etc l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 t\tail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Nlethod of test: VYw1.y '_Jc. For IPater Suooly S Iniecrion Relit: In addition to sending the form to
the addrcsti es) above, also submit one copy of this form vwidurs 30 days of
13b.Disinfection type:� H Amount: completion of well construction to the county health department of the county
,chore conemr,ted.
r9m,QlC•I North Carolim_Deoan Ten!of Er,ironm.-'c-!Q 4:lim-Di':siar,of Wncr R;socr<s