GW1-2022-00883_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I-Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
21 s7-A
fr. ft.
NC Well Connector Certification Number
25.OUTER CASIIVG for mald•eued wells OR LINER(If a Iteable)
Hedden Brothers Well Drilling, Inc FRos, TU DIAMETER rH,c,cvEss MATERIAL
fr. ft. in.
Carnpany Name
I6.DINER CASING OR TUBING f eothermal elosail.1
2.Well Construction Permit;r:_ ��-, FROM To DL01ETER THTCMN-Ess RIA MATEL
List all applicable utll r0natn(cBon pemd1s(.e.WC,Comrty.Stare.Variance,etc.) 0 ft• 4 tt. In. Ike.
3.Well Use(check well use): 11. I . C ft. in. - /RA I�T 6, t
Water Supply Well: 17.SCREEN
FROBt TO DWIETER SLOT SIZE THICKNESS MATERIAL
Agricultural MMumcipal/Pubfic ft.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I in.
IndustriaVCommercial DResidential Water Supply(shared) 18.GROUP
Irrigation FROM TO 1 MATERIAL EMPLACE11E.\TMETHOD&A310LTT
Non-Water Supply Weil: rt. I 20 It ,a I pumped
Monitoring Recovery
Injection Well:
(AquifcrRcchargc OGroundwatcrRcmediation fL fL
19.SAND/GRAVEL PACK if a Hcable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERUL I LNIPLACE,lIE1TMETHOD
Aquifer Test 0-StormwaterDrainage ft. I it
Experimental Technology OSubsidence Control ft. I ft I
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM I TO I DESCRIPTION[color.hardness.sollfrock rrpr rein sires etc.)
0 f`• I ill IL I clay&sand
4.Date Well(s)Completed: Gp'j Well IDn I Q " I f760 f`• I granite
So.Well Location: f` n
ft. ft.
1. io Jones
Facility/OwncrName Facility ID*(if applicable) ft.
� Itc. is.
Physical Address ty.and Zip ft. I ft. jAN _
Count
Y Parcel identification�o.(PIN) -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is sufficient) 22.Certification:
3-6,* 03- 9-9-& �-4 10'es. zf'La'—O� "'3 —
6.Is(are)the wcll(s)3'1113permanent or Temporary Signature ofCcnified well Contractor Date`t'S By signing this form.I hereby certify that c ur/l(s)eras(were)eoarrrtreted in accordance
7.is this a repair to an existing well: n Yes or No stitln 15A NCAC 02C.0100 or ISM,VCAC OIC.0200!F'eii Consrructian Standards and that a
/f this is a repair,fill out knosm cveil construction inforniaiion P.IeTplain the noutre of the copy of this record has been proWeled to the it-ell onner.
repair under 921 reinarkssection or on the backofritirfonn. 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 i OW-1 is needed. Indicate TOTAL AMBER of wells construction details. You may also anach additional pages if necessary.
drilled: /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /00 A) 24a. For All Wells: Submit'this foim within 30 days of completion of well
For multiple wells list all depths iftigerew lerample-3@200'and 2@1001 construction to the foliowine:
10.Static water level below top of casing: I-" (ft.) Division of Water Resources,Information Processing Unit,
ifivater level it above casing.use••_'• 1617 Mail Service Center,Raleigh,NC 2 76 9 9-1 61 7
11.Borehole diameter: (in.) 24b. For Iniection ','ells: In addition to sending the form to the address in 24a
� b above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:_ .u,.r 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc) V
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
13a.Yield(gpm) Method of test• w 24c.For Water Suoolv &Infection 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 type:_ i-tt��f Amount• 1d, Q}� completion of well construction to the county health department of the county
° where constructed.
Fonn OW-1 North Carolina Department of Encironmcncal Qcalir.•-Division of Watcr RcsOLuccs Revised 2-22-2016