GW1-2021-06922_Well Construction - GW1_20210505

_Pr_(_nt Farm
WELL CONSTRUCTION RECORD (OW_I) For Intemal Use Only:
1.Well Contractor information:
Russell Taylor e ms"""" 14.WATER ZONES
Well Contractor Name '4y FROM TO I DESCRIPTION
21$7•A
qq 77 ft. 58a .
021 fr. ft.
NC Well Contractor Certification Number L
j
tq i5.Our CASIlIG for intstH c tsod walls OR LINER of a licable
Redden Brothers Well Drilling, (ngtC,13: 1C�I,rvCr;S51f1rJ 1l�1 FROM TU DiAI1fETER THICKNESS MATERIAL
Company Name
ft. ft. in.
q o 16.INNER CASING OR TUBING eotherma)closed-loo
2.Weli Construction Permit N: o1,0l&^ �J r ^ p 6 J FROM TO DW%IETER I THICKNESS I MATERIAL
List all applicable well construction permits(t.e.U1C.County,State,flariance,etc.) ft. Q 5 ft. 10 in. . 199
1 p !yE�
3.Well Use(check well use): ft. ft. O
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural R)MunicipaUPublic ft. ft. in
:)Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
IndustriallCommercial DResidential Water Supply(shared) 18.GROUT
Itr't ation FROM I TO MATERIAL EINIPLACEittENT EIETHOD&A.li0UNT
Non-Water Supply Well: ft. 20 fL C2 ., pumped
Monitoring Recovery ft. ft.
Injection Well: I
st
ft. 3 ft.
Aquifer RechargeGrouDdwatcr Remediatian i
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery 0,Salinity Barrier FROM TO StxreRlAL V%IPLACEMEN'T METHOD
Aquifer Test ostotmwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. h.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) 00ther(explain under r21 Remarks) FRONT TO DESCRIPTION(color,hardness,soiltrock type,train size,etc.)
f to 5 ft clay&sand
4.Date Wallis)Completed: 4 19 .toz! Well ID# � fr. r700 ft' granite
Sa.Well Location: Ft. ft.
ft, ft.
Facility/O nerName Facility lD:=(if applicable) ft. ft.
4W ITI)ew CreeY_ Rd CW10whee. 4SIA5 ft. ft.
Physical Address,City.an I Zip ft, ft.
_ AeKsaa covory 7537.4-1- 9513 21.REIMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwctl field,one ladlnng is sufficient) 22.Certification:
350 14. 1173 N 085. 1�.3Ja W f l) '�2� � i
6.Is(are)the Wells) permanent or DTemporary Signature of Certified Wcll Contractor- Dar
LL By signing this form.I hereby certo!that r tre11(s)%as(it-ere)constructed in accordance
7.Is this a repair to an existing well: OYes or No xith 15A NCAC 07C.0100 or 15.4 NCAC 02C.0200 Well Constriction Standards and that a
/finis is a relrair,fill out knotvn well eonsertrction inforatation r explain the nature ofthe copy ofthis record has been prorided ra the xell a;rner.
repair under R21 remarkrsection or•on the back ofthisfonn. 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-I is needed. Indicate TOTAL NUMBER of Wells construction details. You may also attach additional pages if necessary.
dtilled: i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 700 0 (ft-) 24a. For All Wells: Submit this form Within 30 days of completion of Weil
For multiple n'ells list all depilts ifd(&-ew li rarnple-3@200'and 3®100') construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
If tearer level is above casing.Ilse'•_" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: „t_ 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: 16.16 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Alethod of test: 24c.For Water Suogly&In(ection'Welis: In addition to sending the form to
.-� the address(es) above, also submit one copy of this form Within 30 days of
13b.Disinfection type: ha amount: completion of well construction to the county health department of the county
tivhere constructed.
Fonn GAY-I North Carolina Department of En ironmcmal Qualin•-Division of ACater Resources Rzvised 2?2-201 b