GW1-2021-02086_Well Construction - GW1_20210706

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WEL.I.CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name MOW TO DESCR1PTtON
2187-A ft. ft.
JUL 0 0 20��
ft. ft.
NC Well Contractor Certification Number
r CCg51Clf�um 1S.OUTER CASING for multi-cased wells OR LINER(If...licable)
Hedden Brothers Well Drilling, lnntrtf�r> aitoll�,O FROd2 TO DIAMETER THICKNESS 'MATERIAL
Company Name
MSrCcf`-�Y�n ft. fL In.
2.Well Construction Permit fi: Q?b070-j9 boC V
e�j, qp-9- 1oqSQ (16.INNER CASING OR TUBING eethermsl closed-loo
FROM To DtAbtETER THiCh'VESS AfATER)AL
Lfst all applicable ur(l consintction petnits(i.c.(AC,County,State,lrarianre.etc.) OM - St 1n.
3.Well Use(check well use): 313 11. 40 ft 1 10 in. I 8 L
Water Supply Well: 17.SCREEN
A Culturnl FROM TO DIAMETER SLOTSIZE THICKNESS AIATERIAL
DMunicipal/Public ft. ft. tit•
Geothermal(Heating/Cooling Supply) MResidential Water Supply
PP Y
IndustriaUCommercial OResidential Water Supply(shared)
I8.GROUT
fill orlon FROM TO I MATERIAL ED[PLtCE1tE\TAIETHOD S A.N10Li%7
Non-Water Supply Well; (0 it. 20 iL tt mat.-ta pumped
Monitoring C31tecovery ft. rt.
Injection Well:
A uifcr Rccha c ft. fL
q � �GroundwatcrRcmediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK ifs livable)
A
q g ry �SalinityBatricr FROM I TO AIATEItLiL EMPLACEMEN'TMETHOD
Aquifer Test ''- Stormwater Drainage ft. to
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) Tracer DRILLL\G LOG funsch additional sheets If nccessar
yl
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) ROD
TO I DESCRIPTIO\ttolor.hardness.si rock type.eraln size,etc.)
rt, OK A g ft-' 1 clay 5 sand
4.Date Well s)Completed:4*1-- Well IDN Ct. fi. granite
52.Well Location: tc. ft.
Jtk&hn tjQ 5 ft.
FacilitylOwnerlame �- Facility 113a(if applicable) ft.
535a Nor+h Noriyn :nWa ►se4ep,,J87U
Physical Address,City.and Zip } ! ��� ft. it
21.R£i4LARKS
County Patccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fccid,one lattlonc is sufficient) 22.Certification-.
3 ° ©9.935 st DS 10�3Gv7
6.Is(are)the well(s), permanent or Temporary Signatttre of Ceniftcd Wcil Contractor Dat
+�+ By signing this fonu,1 herehr Certl that t{uclifsl eras(wrer)consinrctrd in accordance
?.Is this a repair to an existing well: ©Yes or No s ith 15A NCAC 03C.010D ar 15.1 NCAC 07C.0700 Well Constmetion Standards and that a
if this it a repair,fill out knoitw weit ronstnrction information .1-explain site notttre of the copy pfthis record has been providrd to the well owner.
nrpair under 921 rexrarks section or on the back of thisjonn.
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 1 GW-I is needed. Indicate TOTAL)\'UMBER of wells construction details. You may also attach additional pages if necessary.
drilled. ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1000 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple evils list all depths itdifferent ti'ranrple-3(;a 300'and 2@1001 construction to the following:
10.Static water level below top of casing: o0o (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is aharr easing,use _^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b. For Iniection Wells-. in addition to sending the form to the address in 24a
�, - above, also submit one copy of this form ttithin 30 days of completion of Weil
12.Well construction method: (k d_�i'� �LCJ.i; construction to the follott3ng:
(i.c.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\Voter Suvoh•&Infection iWells: In addition to sendine the form to
t the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection hpe: _ Amount: 1 completion of well construction to thla county health department of the counn=
where constructed.
Form Gw-I North Carolina Deoanment of Environmental Quality-Division of Watcr Resources Revised 2-22-2416
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