GW1-2021-06650_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -- --
1.Well Contractor Information:
Russell Taylor 14.WATERZONES
FROM TO DESCRIPTION
WcllContrnctatNoma A R. 8� ft. �O�Q 5
7187-A !
VC Well Contractor Certification Number 180 fr. 185 It _. 40
15.OUTSR CASING for could-cosed wells ORLIPiER.(it applicable)
Hedden Brothers Well Drilling, Inc FROM i TO DIAMETER THICKNESS MATERIAL
ft. fr. !n.
Company Name } D 16.INNER CASING OR TUBING eothermal closed-loop)
0- 41
2.Well Construction Permit#: C J 'I FROM TO DMMETER THICKNESS MATERIAL
Urf all apphtrable welt construction perurits(h.e.UIG County,State,i"arianee,etc.) 0 R. a ft-
t to In.
3.Weli Use(check well use): 8 `a ft. s AT fr in. . 188
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural nMunicipal/Public ft, ft. in.
Geothermal(Heating/Cooiing supply) OResidential Water Supply(single) ft. ft.
Industrial/Comnlercial NResidential Water Supply(shared) 18.GROUT
irri ation FROM I TO MATERIAL I EMPLACEdI 7biETHODS LVIOLIT
Non-Water Supply Gt'ell: 0 ft. 20 fL epnen6eaY,a pumped
Monitoring 1311ecovery fc. ft.
Injection Well: ft ft
Aquifer Recharge DGroundwatcr Rcmediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSaliniry Barrier FROM I TO I MATERIAL I F-MPLACEnIF-N- METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology QSubsidence Control fr. ft.
Geothermal(Closed Loop) °,!Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FRoaI To ! OESCRIPTION(color,hardness,soil/rock type.train site,etc.)
Q ft. T ft. i clay&sand
4.Date Well(s)Completed: / » r rb2l Well ID# 7'4 fr- it' I granite
So.Well Location:
tt. ft.
Hanson
Facility/OwnerName Facility lW appticablc)
131+3 Pb BMX& Pd ci 01134 t[tt.• ffrt..
0
Pbpsleai Address,City,and Zip
iryC(}GL'�
_ rn1t, 6573A %6339 21.REFIARKS „
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wet!field,one hn/long is sufficient) 22.Certification:
5° 35 SRC DR� ° �9 1.06� W
6.Is(are)the wetl(s) Permanent or OTemporarT Signature ofCenified Well Contractor Data
Is By signing tins fort,1 herebr certhy that aaril(s)eras fnrr e)constructed in accordance
7.Is this a repair to an existing well: OYes or Na ttith 13A NCAC 02C.0100 or IS.A NCAC OIC.0200 Well Construction Standards and that a
ifthis is a repair,fill out knosm well co smrction inforrnarlon rri"ecphain the nature aftlu, copy ofthis record has been provided ro the hell auner.
repair under n 21 rental/s section or on lire back ofthis form.
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.
drilled: f SUBMITTAL INSTRUCTION$
9.Total well depth below land surface: 40 (ft-3 24a. For All Wells: Submit this form within 30 days of completion of Weil
Far multiple nvils list all depths i/differem(iwaarple-3Q200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 15 (ft.) Division of Water Resources,Information Processing Unit,
fftvater level is above casing.use"_" I617 Mal!Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Injection Wells-, In addition to sending the form to the address in 242
chore,also submit one copy of this form within 30 days of completion of weii
12.Well construction method: JQ I i), construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS
ELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! \-iethod of test: 24c.For Water S t�oaiv&Injection Wells: In addition to sendine the form to
the address(es) above, also submit'lone copy of this form within 30 days of
13b.Disinfection type:_ r : Amount: d completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Deoanment ofEnvironmcntal Quality-Division of Water Resources Revised'_-22-2016