GW1-2021-06645_Well Construction - GW1_20211007

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WELL CONSTRUCTION RECORD (1GW-1) For Internal Use Only:
1.Weil Contractor Information:
Russell Taylor 14.NVATERZOM
Well Contractor Name FRONI TO I DESCRIPTIUN
2187-A w ft. 10 r2 ft.
ft. M0 ft.
NC Well Contractor Certification Number M OUTER CASING for muld-cased wells OR LINER of up IIcable)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS I+tATER1AL
tt. fL in.
Company Name
16.INNER CASING OR TDBING(geothermal closed-loon)
2.Well Construction Permit m FROM I TO I DIAMETER TMCj7-XESS 1iATERiAL
Lust all applicable null catrstntctfon permits(r.e.UIC,County.State,irariance.etc.) 0 R. ft. I tp In. PVC
3.Well Use(check well use): r7 R. I r(pq It. to in. - 188 t 66 L e
Water Supply Well: FRO CREE,ro DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
Industrial/Commercial 0�,Residential Water Supply shared
i:.l PP Y(shared) IS.GROUT
Irrigation FRONt TO N17TEPJAL ENIPLACE�tE.N'T.NIETHOD S A.ItOLTA\T
Non-Water Supply Well: ft. 20 tL ccmetta:r_:,e pumped
Monitoring Recovery
Injection Well:
ft. it,
Aquifer Rechargc Groundwater Rcmediation 19.SAND/GRAVEL PACK if a Hcable)
Aquifer Storage and Recovery 0,Saliniry Barrier FRO,%J TO SLITERLkL S.viPi ACE1tENT 11ETHOD
Aquifer Test OiStorrnvt-ater Drainage it. fr.
Experimental Technology Subsidence Control a. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION icolor.hardness,satt/rock rain size,etc.)
Geothermal(Hearin Coolin(e�Retqurn) Other(explain under#2l Remarks) r'. ft. 1 162
6 IL day s sand
4.Date Well(s)Completed:_t orI � Well IDfi 1,501 R. ft. f gmnita`
So ell Location:
it. It. {
IJa", Looi Le R ft. ft. 1 .+
Facility/Owner Namc U Facility ID*(if applicable) ft. ft.
I . /N Funmin a?8`134 R. � ft. �
Ira Ta ,r 0611
Physical Address.Cit�p tt. !t. ( r,an •.i4n
Z�JjqUDr.) t..o11n)7-qI 11.REINIA KS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwali ftcld,one lat/long is suRiciont) 22.Certification:
32 11 &50 N . OIB30 16.44.9 w
6.Is(are)the well(s); Permanent or 01remporar), Signature ol'Certified well Contractor Date
By signing this form.i herekr certii i-that u tir4s)it-as orem)coartr cted in accordance
7.Is this a repair to an existing well: nYes or No xirh 15.4 NCAC 02C.0100 or 15.4 XCRC 02C.0200 irefl Construction Standerds and that a
0his it a repair,fill out known well construction infornation P&explain the natutre of the copy of this record has been provided to the imll on7rer.
rcpairunder 921 rmnar/xsection or on the backofthisfann. 1-3.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 QW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
Q9.Total well depth below land surface: OQ (ft-) 24a. For All Wells: Submit this fonts within 30 days of completion of well
For multiple it-ells list all depths/fdiernt tframple-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,
1/water lai el is ahow casing,use"'+" 1617 Hail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 34a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ln �'� construction to the following:
0-auger,rotary,cable,direct push,etc.)
Division of WaterResources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0/-� Method of test: � 24e.For Water Supply&Iniection Wells: In addition to sendine the form to
! the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type:_ t ) Amount: i d completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Emironmental Quality-Division of Watcr Resource's Revised 2"-2016