GW1-2021-03474_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD (GW-2) z�+ For Internal Use Only:
1.Well Contractor information: iteGFD-t 3
VF-
Russell Taylor ate+ 14.WATER ZONES
FROM TO DESCRIPTION
Wc1i Contractor Name „A1 V 7 02� r ft' � 1- �ID
2187-A U{{�� A - ' -
VC Well Contractor CcrtificationNutnber Ifi1Gi tlOUpro.e,ling�nit '394 f" 39'7 ft' +,5 -%.5
Hedden Brothers Well Drilling, Inc [)t+eti s 5e tlon IS'OUTER CASING for multi-cased wells ORLINER fS a liMAT
FROS! TO DIAMETER THlCK.VESS MATERIAL
ft. I j in.
Company Name
I .16.INNER CASING OR.TUBING eothermal closed-loop)
2.Well Construction Permit#: otg -c�6,7&9- g~ �08o5 FROM I TO I DIAMETER I TRICK:NESs I MATERIAL
List all applicable n all construction permits(.e.UIC,County,State,Variance,etc.) o n• 'lip
n. In-
PVC,
IC,
3.Well Use(check well use): AA fr. I
OZ S ft. & in.
Water Supply V+'eil: 17.FRO CAFE To I DIAMETER I SLOTSIZE I THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. I ft. I 'in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROV'r
Irrigation FROM I TO MATERIAL I EMPLACEMENT M€THOD d AMOUNT
Non-Water Supply Well: 0 ft. 20 fL peRH SdepO>'p pumped
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwatcr Remediation
19.SAt\'DlGRAVEL PACK if applicable)
Aquifer Storage and Recovery DSaliniry Barrier FROM To MATERIAL I E>IPLACEME.NT METHOD
Aquifer Test OStorntwater Drainage ft. ft.
Experimental Technology 01 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attacb additional sheets if necessa )
FROM TO DESCRIPTION icolor,hardness,soiltrocl.n e, rain size.etc.)
lGeothermal(Heatine/Cisolin Return) Ocher(explain under�21 Remarks) ft ft
clay&sand
4.Date Well(s)Completed: 1-1'f d604 Well ID# 19
ft. 00 ft' granite
Sa.Well Location: ft. ft.
Sd 4 Swan gya#s ft. ft,
Facility/O�wtner Name +FacilityID#(if applicable) ft. ft.
AICLCX 1l�!04 I �lt,f'11�f I fe�� 46 7.3Lo ft. ft.
P hy deal Address.City,and Zip ft. ft.
Ji aci so" 01'y 76073- 7&- 1993 21.RENURKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latflong is sufficient) 22.Certification:
35 a 09.398 N pesp 05. 539 W 13 a,44a5 at
6.Is(are)the well(s) Fermanent or OTemporary Signature of Certified Well Contractor Date
Aalexpnt
By signing this form,i herebv cert ft that + meU(s)uas(were)constructed in accordance
7.Is this a repair to an existing well• QYes or �No tcith 15A NCAC 02C.0100 or I5A NCAC 02C.0200!felt Constriction Standards and that a
if this is a repair,fill ant knonm well construction fnfornation No
the nantre of the copy of this record has been pro«drd to the nett unmet.
repair under#21 retnank r section or on fire back ofthis fonn.
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 AMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1000 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nuthiple urns list ail depths ifdifjivrnt(example-3Q200'and 2@1001 construction to the following'
10.Static water level below top of casing: ��� (ft.) Division of Water Resources,Information Processing Unit,
If voter level is above caring,use"T" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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 Jt construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY!YELLS ONLY: 1636 Mail SenAce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: &610 24c.For Water Suonly&c Iniection Wells: 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:—5 '--:-C1 Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22.2016