GW1-2022-01890_Well Construction - GW1_20220210

OHntform
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Weil Contractor information:
Russell Taylor 14.R'ATERZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A r` rt
• ft. ft.
VC Well Connector Certification Number
15.OUTER CASING for multhcased wells RLMER(Ifunalicablel
Hedden Brothers Well Drilling, Inc FROM I TO DIAMETER T)IICIcvEss hL1TER[AL
Company Name
fr. ft. in.
�'OC�)- PI 16.INNER CASING OR TQBING eothermal closed-loan)
":
2.Well Construction Permit _ 5 FROM I TO Munk TER TMCtCMS ntATERtAL
Eta all applicable urU construction pemats ii.r-WC.County.State.Variance.eta) 0.R- I58 It- In.
3.Well Use(check well use): 11. I O IL in. 8 Q yr,L e
Wager Supply Well: 17.SCREEN J
FROM TO DIMIETER I SLOT SIZE I THICKNESS 1iATERIAL
Agricultural OMtmicipaWPubffc ft. ft. in.
Geothermal(HeatingiCooling Supply) Residential Water Supply(single) ft. ft. I in.
Industrial/Commercial Residential Water Supply(shared) 1s.GROUT
Irrigation FROM TO JIATERLIL I ENiPLACEML\T tilETiiDD S A.atO[t1T
Non-Water SupplyWell: 0 ft. fL aeesn,e,�„ I pumped
Monitoring Recovery fL ft.
Injection Well:
ft. `Aquifer Recharge �Gtnuadavatcr Rcmediation IL
19.SAND/GRAVEL PACK if a licable)
Aquifer Storage and Recovery Salini Barrier t}' FROAi TU SIATERLIL I L\!P[.ACE1tL\TdIETHOD
Aquifer Test 08torinwaterDrainage tt. l tc
Experimental Technology Subsidence Control fr. tr
Geothermal(Closed Loop) Tracer 20.DRILLL\G LOG(anaeb additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION Icotor,hardness.sailtrock tTPL imin sim etc.)
0 fr. I O fL I clay&sand
4.Date Well(s)Completed: ) Well ID# !SO f- I4,00 fr• I granite
5a.Well Location: ft. ft.
MnooN �1a�t�!-� �f c,�o�. ft. ft.
Facility/OwnerNamc Facility IDR(if applicable) fr. l ft.
fr.Physical Address,City,and Zip fr. I ft.
ivy aN
T1 21.RENL>,RYS
County I Porccl identificarion No.(PIN)
I
5b.Latitude and longitude in degrees/minutesiseconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N
6.Is(are)the well(s) Permanent or 07remporary Signature of Certified Well Contractor Da
By signing:his form.I hereln•eeraf.that t ur11(s)was(were)camiructed in accordance
1.is this a repair to an existing well: [3Yes or No with 15A NCAC 02C.0100 or Ito NCAC 02C.0200!Yell Construction Standards and that a
lfthis is a repair,fill out knoiu iv t r/l construction informationA&rxplain the native ofthe copy g0his record has been provided to the hell oimer.
repair under 921 rrinarks section or on the back ofthis form. 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 IGW-1 is needed. Indicate TOTAL NUhIBER of wells construction details. You may also attach additional pages if necessary.
,
drilled: SUBMITTAL INSTRUCTIONS
J�,/�/'�
9.Total well depth below land surface: -i w (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Formuldplr irells list all depths ifdierent(eratnp/e-3Qa200'artd 2©1001 construction to the followine•
10.Static water level below top of casing: A) (ft.) Diaision of Water Resources,Information Processing Unit,
if ivater level is above casing.use'•_- 1617 Nlait Set-vice Center,Raleigh,NC 2 76 9 9-1 61 7
11.Borehole diameter: (in.) 24b. For Iniection Wells. In addition to sending the form to the address in 24a
L above, also submit one copy'of this form within 30 days of completion of well
12.Well construction method: 1 h , v construction to the folloaaing:,
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Q,, ^ 1636 Mail Service Center,Raleigh,VC 27699-1636
13a.Yield(gpm) 120 Method of test: 24c. For Water Suooh•d Iniecdan_Wells: In addition to sending the form to
I r the address(es) above, also!submit one copy of this form Within 30 days of
13b.Disinfection type: i _ Amount: l ld completion of Nvell construction to the county health department of the county
` where constructed.
Forth G%V-i North Carolina Department of Enairanment:l Qr lin•-Division R:sources Revised 3-2-1-2016