GW1-2021-02467_Well Construction - GW1_20210805

tint Farm
WEEL,L,CONSTRUCTION RECORD (GW-1) I For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14.R`ATERZONES
Well Contractor Name FROM TO I DESCR[PTION
2187-A
fit. fr.
NC Well Contractor Certification Number
IS.OUTER CAS
IIvG far mold-cased weffl OR LINER(if a Iicable)
Hedden Brothers Well Drilling, Inc FROM TO DTAl11ETER THICKNESS lATERIAL
kn.
Company Nameft. I ft.
040 l�,, o -/) 16.INNER CASING OR TUBING eathermal closed-lanni
2.Well Construction Permit#: 1 FROM I TO I DIAMETER I THICh'WN Z'Q I 1ATERIAL
List all applicable well cmutractlon per7l,its r.a.UIC,county,State.Variance.etc.) R. It. /.. in. pp f
tY • 3 C yli...
3.Well Use(check well use). ft. ft. In.
Water Supply Well: 17.SCREEN
FROM To DIAMETER I SLOT SIZE T
THICiewpeS MATERIAL
Agricultural 0MunicipalitPublic fir. ft. in.
Geothermal(14cating/Cooling Supply) OResidential Water Supply(single) ft. io.
IndustriaUCommercial ORcsidential Water Supply(shared)
lt 18.GROUT
�. t'i allow FROM TO MATERIALfENIPt.ACEdIE\•1':IiETHOD S,LtiIOU\7Non-Water Supply Well: l fi. zD fL um,tae,ns,tpumped
t.
Monitoring Recovery fie. fL
Injection WeM
-.�AquifcrReeharge DGroundevatcrRcmediation
Aquifer Storage and Recov 19.SANDIGRAVEL PACK ifa licable
3 DiSalinityBonier FROM TO MATERIAL ME.N-r3WTHOD
Aquifer Test C31Stormwater Drainage ft. ft.
Experimental Technology DISubsidence Control ft. fit
Gcothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Gcothetmal(Heating/Cooling Return) 0 ,Other(explain under#21 Remarks) FROM TO DESCRIPTION teolor.hardness.:orllraek is t,cram slza.etc.)
fit. fit
r� clay&sand
4.Date Well(s)Completed: t S 90A, Well IDmffi-Ifit• f7.?5 ft. grant-to
So.Well Location:
kyr fit. ft.
Foci ity/Ow amc Facility ID#(if applicable) fit. ft. �t
&n_ View rra,nVJin , a.'73q ft, j ft.
Physical Address,City,and Zip ft. I ft.
aeon Ite.z1l+� la5�a�tpa9a5 21.RE}.ARKS t,
County - I Parcel Identification No.(PiN) u 1'iI rJ� `
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees: p6jul 4nd5 boqs
(if wall field,one Iattiong is sufficient) 22.Cestifrco• n:
360 0tv•977 N 0836 a10. 71? W
1,361-0.-1
6.Is(are)the well(s) permanent or E3Temponry Signal=of Certified\Veil Contractor Date
By signing this for7a.1 herebr cert -that r ts'etl(sl was(wrre)constructed fit accordance
I.Is this a repair to an existing well: OYes or No with 15.4 NCAC 02C.010D or 15.1 A`CAC 03GOI00 iYe!/Corulnrctioir Standards and that a
If this is a repair,fell alit know i svell construction inforatalion '.?explain the naittre of the capv otrhfs recortf has been proridrd to the well ouaer.
repair undo a 01 mwarla section or ors the back of this fawn.
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 NUMBER of wells construction details. You may also attach additional pages if uecessmy.
drilled:... [ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of Weil
For'nttt/liple wells list all depths tfdylerent tetarnpir-3@a 200•and 2@100 construction to the following:
10.Static water level below top of casing: aqo (ft.) Division of Water Resources,Information Processing Unit,
I(water level is ahave casing,use••_ ' 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: _ (in.) 24b. For Iniection 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+veil
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) JA Method of test: 24c.For Water Suoui v&Iniection;Wells: In addition to sending the form to
a tt��,.� tt the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: B _ Amount: 1 completion of well construction to tht county'ltealth department of the county
where constructed.
Form GW-I North Carolina Department orEmiranmenial Quality-Division of%Vzter Resources Revised 2 22-2016