GW1-2022-01889_Well Construction - GW1_20220210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATERZONESROM TO DESCRIPTION
FROM ft.
2187-A 90
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a !!cable
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR,TUBING eothermal dosed-loo
2.Well Construction Permit#: 101 FROM TO DIAMJETER THICK,ms MATERIAL
List all applicable Welt construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft- in. /f
16
3.Well Use(check well use): ft. tt. in. / jj Gs
Water Supply Well: 17.SCREEN _ v ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. it. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&Ad10UNT
Non-Water Supply Well: 0 ft. 20 ft, cmeros enure pumped
Monitoring Recovery ft. ft.
]njection Well: fL fL
_Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Saliniry Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTraccr 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under 921 Remarks) FROM TO DESCRIPTION tearer,hardness,soi0roek type. rain size,etc.)
0 it, 0.7 fL day ti sand
4.Date Well(s)Completed: Well ID# Q ft. ft. granite
5a ell Location: ft. ft.
Facility/Owner Name Faeili iD#(ifapplicablc) ft. ft. FEB 1
Physical Address,City,and Zip ft. ft.
VY�� 155 70 613 3 D 21.RENIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lai/long is sufficient) 22.Certification:
35 ' 15 a 674 N 10 3 ' S3, 831 W zEQ:At 1 an,Ia,1
6.Is(are)the well(s) Permanent or E3Temporary Signature of Certified Well Contractor Date
Po�,,ain
By signing this farm,I herebv ce �•that t np!!s)Ives(were)constructed in accordance
7.Is this a repair to an existing well: QYes orowith 15A NCAC 02C.0i00 or ISA NCAC 01C.0200 Mell Construction Standards and char a
ifthis is a repair•fill art known well construction info nmatian the nature of the copy of this record has been provided to rho itel/oxrer.
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 GW-I �s 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: IS d0 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple,veils list all depths ifdii ferent(erample-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 150 (ft.) Division of duster Resources,Information Processing Unit,
1fuater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:':In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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
13a.Yield(gpm) 5� Method of test: &too 24c. For Water Suanly&Iniechon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1-?� Amount: 61 completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016