GW1-2022-00900_Well Construction - GW1_20220107

Prinf Form
WELL CONSTRUCTION RECORD (GW-1) For InterrIal Use Only: --
1.Well Contractor Information:
Russell Taylor 14. 1ATERZONES
1Vc11 Contractor Name FRO4 TO DESCRIPTION
2187-A 2A 4ft' 1 0 7 ft'
ft. fr.
NC Well Contractor Certification Number
I5.OUTER CASING for rnuld-cased wellsil OR LINER(If applicable)
Hedden Brothers Well Drilling, Inc FROM To DIAMETER fRiC VEss MATERIALCompany Name
It.
% in,
O�'Q^' ^ 16.DINER CASING OR TUBING eotheemm ei—aa-
2.Well Construction Permit: Idol f/ FROM To DL1.\tETra Tarc��tEss <fATERtat
tGrt all applicable uell construction petarits 111-UIC.Cotutly.State,Variance.etc.) ft• rL ln. PV G
3.Well Use(check well use): 44 It. I ft 107 in. log
sT
Water Supply Well: 17.SCREEN
A Cultural FROM TO DIMIETER SLOTSIZE THICIC"N SS MATERLIL
�Municipal/Public ft. ft. Na•
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single)
ft. in.
lndustriayCommercial OlResidential Water Supply(shared) ft.
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEME\TJfETHODS.4tlOItT7
Non-Water Supply Well: tt zo fz ttcx,d evu.,a pumped
Monitoring Recovery
injection 1Ve11:
AquifcrRecharge DGroundwaterRcmediation
Aquifer Storage and Recovc 19.S AND/GRAVEL PACK if a Ucable)
tYSaliniryHarricr FROM AFTO
ataTERut E\TPLACE1fE\T�IETHOD
Aquifer Test !OStormwater Drainage tt. tr
Experimental Technology Subsidence Control fr. fr.
Geothermal(Closed Loap) Tracer 20.DRILLING LOG attach additional sheets if necessa )
Geothermal(Hearin Coolin Retum) Other(ex lain under�21 Remarks) FROM To DESCRIPTION!color,hardness,sonfrock a rota star.err t
n aay 6 sand
4.Date Well(s)Completed: t7f 17 Well ID fr. ft. I arentte
go.Well Location: ft. AM ft.
ejxjj h5 ` ft.
Facili OwncrNamc Facility ID#(ifapplicable) ft. JA
ft.
d tt. _
Physical Address,City,and Zip I fr. I ft.
caa Cku0n�_ 7�43 9g919 �a 21.RE1L4RK$ e
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/lone is sufficient) 22.Certification:
3510 a1.310.7 IV 0830 W. 71 W
��j( m �v>a ao a �
6.Is(are)the well(s)4 peranent or Temporary Signature ofCettificd tVdl Contactor Date
""''�� 0,7&'e.vplaintlicitaitire-ofthe
B)•signing thisfornt.I hereby eertifit that i urll(s)eras(were)eotutntcted in accordance
7.Is this a repair to an existing well: QYes orNo With 15A NCAC 02C.0100 or IS.d NCAC 03C.0200 rMell Constmeriou Standards and that a
if this is a repair,fill out*nounWell construction itrforniahioo -copy Rf this record has been providrd to the well owner.
-poll-under 821 reoarla section or on rite back ofibis 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 N NIBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUB'MITTAL INSTRUCTIONS
9.Total well depth below land surface: A100 (ft.) 24a. For Ali Wells: Submit this form ",ithin 30 days of completion of well
For multiple Wells list all depths ifdifferent(eranrple-3@26 'and 2@1001 construction to the following:
10.Static water level below top of casing: 105 (ft.) Dhisfon of Witter Resources,Information Processing Unit,
Ifivater level is above casing,rise'•+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: (in-) 24b. For Iniection Wells:. In addition to sending the form to the address in 24a
n 11 ,,W tti— P'Q above, also submit one copy of this form nithin 30 days of completion of well
12.Well construction method:_S! `j � construction to the following:
0i 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
13a.Yield(gpm) Method of test: 24c.For Water Suooly S Iniection Wells: In addition to sendine the form to
�► I the address(es) above, also submit one copy of this form within 30 days of
A13b.Disinfection type: � 1-1 amount: i d completion of neli construction to the county health department of the county
where constructed.
Fonn MA'.I North Carolina Deoarment of Environmcnial Qualiry-Division oft."atcr Resources Revised 2-22-2016