GW1-2021-06921_Well Construction - GW1_20210505

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WELL CONSTRUCTION RECORD {GW-D For Internal Use Only:
1.Well Contractor information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2187-A 7 ft. 02 fc. D -1+Q
D
NC Well Contractor Certification Number 15.OUTER CASING for mulft.eased wells OR LINER(if o ticab)e)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
fr. fr. ln.
Company Name
.Ib.INNER CASING OR TUBING( eothermal closeddoo
2.Well Construction PerWt#: of�f 0icJ"/4 D55-9" 7465 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,cell construction pet»tits(i.c.UIC,County,State,Irar•rance,eir.J 0 ft. ft. to 1 in. /ry,/
3.Well Use(check well use): sg ft. 0.t�s$ IS EE L
Water Supply Well: 17.SCREEN
DlAbiETER: SLOTS€"LE THRCK\EIS
Agricultural E)MunicipaUPublic FROMft. TO ft. in: :tiATERtAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft,
Industriavcommercial 0Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO JATERIAL EMPLACEMENT METHOD&&A..NIOuNT
Non-Water Supply Well: ft. 20 It. ern erg„ pumped
Monitoring Maccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAtNrD/GRAVEL PACK if a Hcable)
Aquifer Storage and Recovery Salinity Barrier FROM TO NIATERRAL ESfPLACEME.N-T METHOD
Aquifer Test Ostormwater Drainage ft, tr 1
Experimental Technology D-Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTI type,(color,hardness.soittrock e, ram size,otc.l
ft. p-p ft. clay 5 sand
4.Date Well(s)Completed: 4 Well ID# ft. gmnite
Sa.Well Location: ft. ft.
ryeeC.
Facility/OwnerNamc ))11 Facility ID (ifapplicable) ft. ft. `5� t-
)14
tLT+• 3 43 CQ,Sti��rS as?�? tt. ft. r
YIY h
ft. I ft. ° '
Physical A d ss,City,and
,��,Zip 21.RE1L4RK5
ny
l.(3ALIq _ O.?"!}
County Parccl Identification No.(PIN) V EiY R �y3 0
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
tifwcll field,one lat/long is sufficient) 22.Certification: /�/�
0,35 bt7..31nn N 08.92 Q 7Jr5. w / �.� �3 4 17 AV&1)
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date or f
By signing this form,I hereby certify that t uell(s1 nas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or Pexplainflenalurroffhe
No pith ISA NCAC 01C.0100 or 15.4 NCAC 03C.0300 Well Construction Standards and that a
lfthis is a repair,fill out knaua well cansiniction infonsaiion copy of this record has been provided to the well ox•ner.
repair under R21 renianks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only(GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled' I I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiij)�r•eni ikxample-3Q?00'va}nd 3Q1001 construction to the following:
10.Static water level below top of casing: da0 (ft.) Diiision of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing,use"_" 1617 flail Semice Center,Raleigh,NC 27699.1617
11.Borehole diameter: _�(in.) 24b.For Inlection Wells In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY!-WELLS ONLY: rM1�1 1636 M211 Ser%ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) iP Q Method of test: 011D 24c.For Water Suonly & Infection Wells: In addition to sending the form to
fi� the address(es) above. also submit one copy of this form within 30 days of
13b.Disinfection type: i 1 Amount: completion of well construction to the county health department of the county
where constructed•
Fonn GW-1 North Carolina Department orEnvironmcniai Quality-Division of Watcr Resources Raised 2.22-2016