GW1-2022-01891_Well Construction - GW1_20220210

_ Pri�t�Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM I TO I DESCRIPTION
2187-A (� 1t. r7l it. _
NC Well Contractor Certification Numbs fG .
is,OUTER CASING for multicsed wells OR LINER(If a cable)
Hedden Brothers Well Drilling, Inc FROM TD DIAMETER I THIctcMS NATERM
R.
Company Nameft. I I In,
16.INNER CAMGOR TUB ING clatedJoinnA
1.Well Construction Permit I4A2I-P FROM To DtA,%1=R I TBtcrv'�wss I %IATER1Ar.
L(sr all appllrable rtrll canstmetlon perrrrlts(r.a.EIiC,Counry,State,Variance,etc) 0 n. IL in.
3.Well Use(check well use): TT R• , r� ft in. ' TPE
Water Supply Well: 17.SCREEN G W
FROM TO DIAMETER SLOTSIZE THICKNESS diATERLIL
Agricultural nMunicipal/Public ti, n In,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 19.GROUT
irrigation FROM TO MATEMAL EMPLACEIIL\TMETHOD S A.\iOLl7
Non-Water Supply Well: t zo tL � I pumped
Monitoring ORecovery ft. ft.
Injection Weil:
Cr. I ft-
Aquifer Recharge Groundwater Rcmediation
I9.SAND/GRAVEL,PACK if a lieable)
Aquifer Storage and Recovery [D-Salinity Barrier FROM To SIATERL\L NIPLACEMEN'T}IETHOD
Aquifer Test E2Stormwater Drainage tt. I iz
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 21.DILLING LOG attach additionsI sheets if necessary)
Geothermal(Hearin 0 Cooling Retum) Other(explain under#21 Remarks) *•-ROM R To I DESCRIPTION leolor.hardnem salUraek nve.gram siz4 etc.)
at S Sand
4.Date Well(s)Completed: Well M fr. iL ' granite
go.Well Location; ft. n.
FacilitflOwncrName Facility lDO(ifapplicablc)
ft. ft.
Physical Address,City.and Zip ft. I ft.
,
r750&57,,+i&p 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
-39* L3. D836 zfALQ4,tE, � 15 0
6.Is(are)the well(s) Permanent or OTemporary Signature ofCersificd Well Contractor Dart
By signing this farm.1 herein-certify that t ur1l(sJ tress(weir)eanrinreted in accordance
I.is this a repair to an existing well: nYes or No »kilt ISA NCAC 02C.0100 or 1S.4,VCAC 02C.0200 Well Construction Standards and drat a
/f(leis is a repair,fill out knot nvell construction informationA#Iexpiain the natures ojthe copy orthis retard has been provided to the it-ell ourrer.
repair under 921 remar,CTseetion or an rite back afdrisfann. 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 GW-1 is needed. Indicate TOTAL NtLR•1BER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 57.E (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nr/ls list all depths/fdierent(erample-3Q200'and 2Q1001 construction to the following'
10.Static water level below top of casing: 17o (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" I617 Mail Ser�'ice Center,Raleigh,NC 2 76 9 9-1 61 7
11.Borehole diameter:,_�_(In.) 24b. For Injection Weill: 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: aLi I,Ti 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 27699-1636
13a.Yield(gpm) &0 dlethod of test 24c.For Rater Suooly&Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection t'pe: Amount: 0 completion of well construction to the county health department of the count'
where constructed.
Form 0\11-1 North Carolina Deoarment ofEnviranmantzi Qualiry-Division o:\':a:cr Resources Revised Z 22-1016