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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: -
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES I
Well Coaaactar Name FROM TO DESCRIPTION
2187-A Pit "' /45 i 93- 198
•NC Well Contractor Certification Number aVD R. €285
15.OUTER CASING(for multi-cased wells)OR LINER(nap cable)
Hedden Brothers Well Drilling, Inc FROM To DIAMETER , THICKNESS MATERIAL
R. ft. In. -
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: DIDQga0,21-1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) 0 ft- 50 It.. )„ In. p`'C.
3.Well Use(check well use): 5() it, I .5q f- Le in. . /88 S TEE L.Water Supply Well: 17.SCREEN X •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft, ft. I in.
Geothermal(Heating/Cooling Supply) i'fkResidential Water Supply(single) ft, ft, in.
Industrial/Commercial DResidential Water Supply(shared) Is.GROUT
Irrigation FROM TO 1 M A.
MOUNT
I EMPLACEMENT METHOD
Non-Water Supply Well: 0 ft• I 20 a- aeaaanx:,. pumped
Monitoring- DRecovery ft. I it. 1
njection Well:
fr. I fAquifer Recharge 0GroundwaterRcmediation Aquifer Storage and Recovery Sa[ini Barrier 19.SAND/GRAVEL PACK inapplicable)
ry FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test (jStormwaterDrainage ft. I ft.
Experimental Technology DSubsidence Control ft. I ft. I I
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Hearin Coolie Return) FROM I TO i DESCRIPTION(color.hardness.makecI tepe,grain size.etc.)
(Heating/Cooling Other(explain under#21 Remarks) ft I ua 0 '.. clay a.sand
4.Date Well(s)Completed: "9IaSl a2 Well ID;r 41,a fr. WO ft. granite
Sa.Well Location:
ft. fi-
Al2.1_,'r._1L_ ft. I ft. _
-
Facility//O{4maNNloi�ncc� {{�� ,FacilityIIDnD__(ifapplicable)�/� ft. i ft. li
3807 Phftana. Kd. ho.( a. yl )a8 I3.3 ft. I ft. MAR
Physicall1 Address.City.and Zip ft. I ft. ` �0�9
L�t�nm eounry ,5(a94o -loot% I 21.REMARKS
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one fat/long is sufficient) 22.Certification:
3.5°a5.ao8 N 683° Nt3- tog w7e60.4..eff 8 a
6.Is(are)the wcll(s) m Peranent or OTemporary Signature of Certified Welt Contractor Date
By signing this Joan.I hereby certO that t•t r/1(s)was(weir)constructed in accordance
1.Is this a repair to an existing well: Dyes or No with ISA NCAC 02C.0100 or IS.4 NCAC 02C.0200 Well Construction&anderdr and that a
If Mr it a repair,f l out knelt'',well construction information teesplain the nature of the copy ofthis record has been provided to thew 11 owner.
repair under 01 rrnnarls section or on the back of this 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 1 GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional gages if necessary.
drilled: 1SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdif rent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 65 (ft.) Division of Water Resources,Information Processing Unit,
((water level is above easing,use'='• 1617 Mail Service Center,Raleigh,NC 276 99-1 61 7
11.Borehole diameter: IS (in.) 14b.For Injection\Veils: 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: C�h, construction to the following: 1
(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) IP Method of test 610143 24c.For Water Supply&Injection Wells: In addition to sending the form to
! the address(es) above, also submit one copy of this form within 30 days of
'$ I L Amount: `d completion of well construction to the county health department of the county13b.Disinfection type: k"
L where conswcted.
Form GW-1 North Carolina Department of Emiroamental Quality-Division of Water Resources Raised?22-2016