GW1-2021-06656_Well Construction - GW1_20210706

:: P�int'Form .
WELL CONSTRUCTION RECORD CW-1} For Internal Use Only: --
1.Well Contractor Information:
Russell Taylor t1d
Ia.WATER ZONES
Well Contractor Name
�m FROM TO DESCRIPTION
s�•�"""
2187-A
NC Weli Contractor Certification Number prOCL,C --lad i5,BUTER CASING for multi-cased wells ORLINER if n ]Icable}
Hedden Brothers Well Drilling, IpC �tltlli �tsC1(1 FROM TO DIAMETER THlCKYESS MATERIAL
d-. .ni���,}P+� ft. ft. In.
Company Name -.�T
pq 16.INNERCASINGORTUBINGi eothermalctosed-lop
2.Well Construction Permit M 6tpiQ"tA 14D(07'7 FROM I To I DIAMETER I THICI.'YESs I MATERIAL
Un all applicable aril corstnictlon permits(i.e.IIIC.County.State,Variance,etc.) O tt• la
rL In.
nYC
3.Well Use(check(veil use): )i 8 ". 1.20 ft. In. � ��g f
Water Supply Y+'ell: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public fr. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In.
-, Industrial/Commerciai DResidential Water Supply(shared) 18.GROAT
1ni ation FROM TO MATERIAL EMPLACEAIENT~iETHOD d:A.NIO(t,1T
Non-Water Supply Weil: ft. 20 rL ,nakn-.t pumped
Monitoring Recovery It. ft.
Infection Well:
'.- Aquifer Recharge naroundwatcr Remediation ft tt
19.SANDIGRAVEL PACK if i licabie)
Aquifer Storage and Recovery 0,$alinity Barrier FROM I TO MATERUL EMPLACEMENT METHOD
i Aquifer Test 0stormwater Drainage tt. tt
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return} Other(explain under f21 Remarks) FROM TO DESCRIPTION(color.hardness,soiltroch type.2roin sire.etc.)
9„ ft. day&Sand
4.Date Well(S)Completed: Well ID# F 1 o €t. goo ft. f aranire
fr.
So.Well Location: It.
{Ay. LL-G ft. ft.
Facility/OwnerNamc Facility IV#(if applicable) tt. ft.
WOrny Cftk' - fFa, ttj t�hren?,21_1 Ct. €t. '
Physical Address.City,and Zip Ct. ft.
JACKsONS .Dw1 75 t7e?— S I-—S4J7$ 21.RENLAIM
County Parcel Identification No.(PIN:)
5b.Lntitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lot/long is su0ieient) 22.Certification:
6.Is(eire)the well(s) Permanent or OTemporary Signature of Certified Well Conrractor Date
By signing this form.!hprebr eertfr that t uell(s)teas(were)con trusted in accordance
?.Is this a repair to an wdsting well: MYes orA.,
No with 15.4 NCAC 02C.0100 or l5�i NCAC 02C.o700 n'e11 Cansinrctiotr Standards and that a
/f this it a repair,fill oat knower well eastnrction tnfanaattanesplaiu the naarre of tit copy ofthis record has been provided to the hell saner.
repair taider 921 remark section or on the bark,afthisfartn. 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 I GW-I is needed. Indicate TOTAL A'UhiBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL IN
9.Total well depth below land surface: 600 r-) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtlferent(erarrtple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
)ftvatwlevel is ahotm casing,use'•=" I617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter:_ �_(in.) 24b.For Injection 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: I tt 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: b +�� 24c.For Water Suooly&Infection Wells: In addition to sending the form to
t� the address(es) above, also submit 'one copy of this form Nviihin 30 days of
13b.Disinfection type: I�_ Amount: 0 completion of well construction to the county health department of the count),
where constructed. y
Font)OW-1 ?north Carolina Department of Environmental Qu lit)•-Division oft;'atcr Resources � Revised?22-10 i 6
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