GW1-2021-00039_Well Construction - GW1_20211109

klnt'Form
WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: - -"
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES i
Well Contractor Name FROM I TO DESCRIPTION
21 s7-A 74 ft. 7 ft
NC Well Contractor Certification Number
7 ft. ft.
IS-OUTER CASIIIG for multi-eased walls ORLINER(if a lfcable Hedden Brothers Well Drilling, Inc FRObI TO DIAi1tETER THI WNESs MATERIAL
Company Name ft. fL in.
_ 9 � 16.4�\ERCASINGORTUBING eoMermal2.Well Construction Permit#: odo?1—a?1934 TcAltiCI'-'NW
S MATERIAL
I PVC
Uat all appllcable trelt consarterion permits ft.e WC.Cotarry.Stare.Irariance.eta) 0 ft. 1 ft. in.
3.Well Use(check well use): r73 �88 STEEL
Water Supply Well: 17.SCREEN
Agriculture) Munici itUPublic BRORi TO DiAAMILA SLUTSIZE THICiGNESS MATERIAL
P ft. ft. to
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commereial DResidential Water Supply(shared) ft. ft. io.
]tri tion 18.GROUT
FROM TO d1ATEAIAL EMPL4CEdIE�7METH0 &A.tfOCTT Non-Water Supply Well:
ft. Zp CL remenatxa:,e pumped
Monitoring Recovery ft ft.
Injection tiVell:
AquifcrRccharge [)GmundwatcrRemediation ft. I ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK if a Iicable
OSaliniry terDr FROM To NL4'TERL%L E.IIPLACEME.NiTMETHOD
Aquifer Test �StormwaterDrainage ft. ft:
Experimental Technology Subsidence Control fr. ft.
Geotheimal(Closed Loop) Tracer 20.DR[LLL'G LOG(attach additional sheets if neeessa )
Geothermal(Heatin Coolie Return) 10ther(explain under#21 Remarks) Fro^i Ta DFSCRIPTfO\teotor.hardness,soiUroek a r: sim etc.)
ft' I fG ( clay 8 sand
4.Date Well(s)Completed:46��
Well M4
ft. 0D ft. I granite
So Well Location: ft. ft.
lealI B"wn ft. rL
Facility/Owner\Name � FacilirylDa(iiffaeppiabliicablle)) ft. ft.
0 `1r' '1l t 28 L 1'_ —FT—ft. I --
physical Address.City.and Zip ft. fr.
JAC1l.5Dn) cw"y r1573-SB- 21.RENlARKS
County Parcel identification No.(PIN) UUa8 SLUM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/lonc is sufficient) 22.Certification:
.350 09.808 r, 0° 05.83.3 W
6.Is(are)the wells) Permanent or ElTemporary Signatura ofCertificd Well Contractor! Date By signing this form.1 herein•certify that r aril(s)was(nor)eonctntcrrd in accordance
7.Is this a repair to an existing ivell: DYes or0.1'explain
No aith 1SA NCAC 02C.0100 or/SA NCAC 02C.0200(Yell Construction Standards and that a
trihis is a repair,fill ortt knows wrll emrsinecrion information the nauere ofthe copy ofthis record has been provided ro the nrll oumer.
repair under 921 remarks section or on the back of this 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 1 CxW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15M (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For ntukiple.%yells list all depths ifdierent tkvarnp/e-3Q200'andd 2Q100'1 construction to the following:
10.Static tvater level below top of casing: 6 (ft.) Division of Water Resources,Information Processing UnI%
1(tvater level is above cosine.trse' 1617 Mail 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
L v� above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_ �� construction to the following:
0.e,auger,rotary,cable•direct path,etc.)
Division of Water Resources,4Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 921P5 Method of test: WSJ 24c.For Water Suonly&Injection Wells: In addition to sending the form to
tt�� ff the address(es) above, also submit one copy of this form uithiD 30 days of
13b.Disinfection hype: Amount: 4 completion of[tell construction to the county health department of the county
where constructed.
Form G11'-i North Carolina Department of'Emiranmental Quality-Division ofWaLer Resources Revised 2-22-2016