GW1-2021-00051_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD (GW 1) __Print Forlii
For Internal Use Only:
I.Well Contractor information:
Russell Taylor 14.WATER ZONES
WCII Contractor Name FROM TO DESCRIPTION
2187-A ft.
NC Well contractor Certification Number ft. ft.
I5.OUTER CASDVG for multi-cased wells ORLTNER(if a Ilcahie
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICK•tEss AfATERLIL
Company Name ft ft. in.
16.INNER CASING OR TUBING,(... e al closeddoo
2.Well Construction Permit;.: i07 nLo.�I n FROM I To I DU-1ETER
Us(aft applicable i elf ronsmiclion petan (L ts e UX,County,Stare,1r 'ante,etc.) R, 01 - IL 10 In, TArct`YFss MATERIAL
3.Well Use(check well use): U ft. L to
lIn.
Water Supply Well: 17.SCREEN L
LIn
ultural FROM To D1AAIETER SLOT SIZE THICiG�FSS MATERIAL MunicipabTublic ft. ft. in.
ermal(Henting/Cooling Supply) Residential Water Supply(single)
trial/Commercial ft•
Residential Water Supply(shared) 1g,GROAT
nion MATERIAL EAIPLACEAIE A[AIETHOD S A.NIOCNT
ater Supply Weil: fL PO CL re enatr ." pumped
itoring Recovery ft.on Well:fer Recharge DGroundwatcr Rcmediation ft.
fer Storage and Recove 19.SAND/GRAVEL PACK if a ucable4 DiSalinityBarrier FROM TO MATERIAL EXPLACEME\TAIErHOD
fer Test oStormwater Drainage ft. fc
mental Technology Subsidence Control ft. faermal(Closed Loop) 0-Trecer 20.DRILLING LOG attach additional sheets ifnecessa }ermal(Hearin Cooling Return) Other(ex lain under±21 Remarks) 1•>zogt To DESCRIPTION ncolor.Iurdness,sotOroek ran size,eta)
R' ( 8 U clay&sand
4.Date Well(s)Completed:44L"J- Well ID# 38 ft. �ft-
granite
So.Well Location: R. tt.
1 �L fr, ft.
Faciliitrty(Owntt\am Facility iD (ifapplicablc) ft. ft. i
l2� Y►tlirLl n..o F n"in a8� 4 It. I rt.
Physical Address,City,and Zip fr. I R. NOV
92021
mftiQ C L Nr j g5333q►9 8 9 21.REMARKS
County Parcel identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1t'FOf7MATi(1�l FRnrE$SI 7
(ifwcll field,one lavlong is sufficient) 23.Certification:
35� q W
6.Is(are)the wells) permanent or OTemporary. Signature ofQvified well Contractor ; Date
By signing this form,1 herebv certify that tuns fur r)eonvi acted in accordance
7.Is this a repair to an existing well: rJ Yes or No with 15A NCAC 02C_0100 or 15.4 NCAC 02C.0200 tiell Consintcton Standards and thin a
Olds is a repair•fill out knmhst,veil eonsirttction information tdesplain the nantre ofthe copy ofthis record has been provided to the tsell onner.
repair totder 421 renhardr section or on the back ofthis faint.
23.Site diagram or additional well details:
8.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 GW-i is needed. Indicate TOTAL NUh1BER of wells construction details. You may also anach additional pages if necessary.
drilled: 1
_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: U1 000 (M) 24s. For All Wells: Submit this form within 30 days of completion of well
For nnthiple.wells list all depths ffd ferent(ermttple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if hater level is ahovr rasing.use••+•• 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
n� 11 n above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:—_Lt h� f t LZ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water SUDDiy S Iniection Wells: In addition to sendine the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection hype: l amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonh Carolina Department of Enviranmencal Quality-Division of W ater Resources Revised 2-22-2016