GW1-2021-06328_Well Construction - GW1_20210915

-P_hf Form
WELL CONSTRUCTION RECORD (GPI-1) For Internal Use Only: -
1.Well Contractor Information: v-
Russel!Taylor
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A 0 rt. e.
�iZl art, 5 f` 1649-573
sIC Well Contractor Certification Number • 15.OUTER CASING for multi-cased wells OR LINER(if a licable)
Redden Brothers Well Drilling, Inc .{�,`1�t e,`OS% � �` FROMTU bTA4iETER TH[CK�2ES5 51ATERtAL
ft. ft in.
Company Name a
o�Q!$$ 7 I��a�5 16.INNER CASING OR TUBING(geothermal closeddoo
2.Well Construction Permit R - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable nrll constntciton permits(t.c.UIC,County,Stare,Yariance•etc.) ft. Cl01t. 1 In.
3.Well Use(check well use): g0 ft. ! ft. In. t g8
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
_ al/Public
Agricultural Munici
P it.
Geothermal(14enting/Cooling Supply) MResidential Water Supply(single) ft.
1ndustrial/Commercial OResidential Water Supply(shared) is.GROUT
Irrs ation FROM I TO MATERIAL EMPLACEME.\"rrMETHOD&i1TOtL\7
Non-Water Supply Well: ft, zo rL eemeusc�aro pumped
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundtwatcr Remediadon
19.SAND/GRAVEL PACK if analicabto)
Aquifer Storage and Recovery Salinity Harrier FROM TO MATERIAL E\fPLACEDIE\T btETHOD
Aquifer Test C3Stormwater Drainage ft. ft
71 Experimental Technology DiSubsidence Control tt. ft.
Geothermal(Closed Loop) Tracer 24.DRIU 7G LOG attach EL__
Geothermal sheets if necessary)
Geothermal(Heatin Cooling Return) ; ,Other(explain under#21 Remarks) FROM TO DESCRIPTION tcolor.hardness,soiVrock type.grain size.etc..
( ; fr. it clay&sand
4.Date Well(s)Completed: Well IDg OoZ ft. fr. granite
So.Well Location:
1•l it' ft•
icko t w W Q!!/r e-
Facility/owner Name /F�a�cility ID#(if applicable) it• it•
Lib Mj -
Ph}•sisal Address,City,and Zip ICt. ft.
"kuon �',ak"W �jlo�3~lot) 45*1 21.RENIARKS
County 1 Parcel identification Na.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22.Certification:
3 Verb
4.395 N =° 18.5'7o W A&aneff ] $ l
6.Is(are)the well(s) permanent or OTemporary Signature of Certified%Veil Contractor Date
By signing this form.I herebr certify that t.srell(s)was(were)conrtntcted in accordance
I.Is this a repair to an existing well: nYes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 lVell Consinrction Standards and that a
tf flits is a repair.fill ottt knoxrt well cotrslntetion informationA&-erpl
ain rho nature ofthe copy of this record has been provided to the tseli or%-ner.
repair under#21 remarlssection or air rite back ofthisfarrm 23.Site diagram or additional well details:
8.For GeoprobelDPT 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 NU1b1BER of wells construction details. You may also attach additional pages if necessary.
drilled: j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 10125 (ft.) 24a. For All Wells- Submit this form within 30 days of completion of Weil
For multiple wells list all depths trdii ferent rorample-3@200'and 2@100q construction to the following:
10.Static water level below top of casing: j!1515 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing.use"4,. 1617 bail 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3D Method of test: 24c.For Water Suph•&Iniection Wells: In addition to sendine the form to
the address(es) above, also submit; one copy of this form within 30 days of
13b.Disinfection tv e: Amount: �l1 completion of well construction to the county health department of the county
where constntcted.
Form GWI North Carolina Deoanmm of Environmental Quality-Division of%%'atcr Resources Revised 2-22-2016