GW1-2021-02487_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-b For Internal Use Only: -
I.Well Contractor Information:
Russell Taylor la.wATERZoIVEs
Well Contractor Name FRWO TO DESCRIPTION
It, ft.
2187-A
• ft. fx.
VC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER(if o Hcoble)
Heddef)Brothers Well Drilling, Inc FROM TO DIAMETER THICKNESS 1tATEFUAL
ft. fL
Company Name In.
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit;":_ tq I FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable troll construction permits(i.e.WC,County.State,Irariance,etc.) 0 ft. In. /SYL+
3.Well Use(check well use): in. I gg S 7S 15L_ e
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSLZE I THICKNESS I MATERIAL.
Agricultural [3Municipal/Public ft. ft. In.
G m eotheral(14enting/Cooling Supply) WResidential Water Supply(single) ft. ft. in.
m
Industrial/Comercial Residential Water Supply(shared) IS.GROUT
irrigation FROM I TO MATERIAL I EMPL4CEmF-N-rMETHOD S Amou-NT
Non-Water Supply Well: ft. 20 ft* cemen8eenr n pumped
Monitoring 13Recovery ft. ft.
Injection Well:
•.. AquifcrRcchargc 0GroundwatcrRemt:diation t
19.SAtNDIGRAVEL PACK it licabte
Aquifer Storage and Recovery 0,Salinity Harrier FROM TO MATERIAL I VVIPLACEMV T METHOD
Aquifer Test iOStormwaterDrainage ft• [r
Experimental Technology D!SubsidenceControI fr. ft.
Geothermal(Closed Loop) ©tTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return ? FROM TO i DESCRIPTION tcolor.hardness.soittrock n'e.grain size.etc.)
} Other(explain under f_1 Remarks) 0 ft. I clay s sand
4.Date Well(s)Completed:—q&P-04L
Well IDS r1 14f` 1000 f`• granita
So.Well Location: ft. ft. j
JV' Xt/ Vole ft, ft.
FacilitytOwncrName Facility IDa(if applicable) ft. fr.
307 l.ba'J' i s cl'cey- -Xid](A19A e o&179
Physical Address,City,and Zr t J fr.
fac t ,n '759 1-9:ln-' Sa.1 21.REh1ARKS
County Parcel Identification No.(PINi
Sb.Latitude and longitude in degrees/Ininutestseconds or decimal degrees:
(if watt field.one latllong is sufficient) 22.Certification:
sue' Iiie Q%Z N DI A75 W za t.]CLAq AV� r7
6.Is(are)the well(s) Xpermanent or 07remporary Signature of Certified Well Contractor Data
By signing this f01711.I hereby certi'that i nrll(sl+ras(were)constructed in accordance
7.Is this a repair to an existing well: n Yes or No with 15.4 NCAC 02C.0100 or 15.4 JVCAC 02C.0200 17'ell Consiniction Standards and that u
Ifthis is a repair,fill out knoam ivell construction Ltforination Axplain the uahrre Rtthe copy ofthis record has been provided to the well ow-ner.
repair under 421 remarks section or on the bark of thisfonn.
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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: boo (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulripta urns list all depths ifderent irrnntple-3@200'mid 2(n}I00'1 construction to the follotvine:
10.Static water level below top of casing: j 000 (ft.) Division of Writer Resources,Information Processing Unit,
I,fwater level is above casing,use"T" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells:- In addition to sending the form to tite address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ti 11t construction to the folio-.Ving:
(i.e.auger,rotary,cable,direct push,etc.) 1
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 Method of test: 24c.For Water Sunni•&Iniectio iri Wells: In addition to sending the form to
S the address(es) above, also submit "one copy of this form within 30 days of
13b.Disinfection type: F'T Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Notth Carolina Department of Emironmeata)Quality-Division of Watcr Rcsourc s Revised 2-32-20 i 6