WI0100436_Geothermal Well Construction Record (GW1)_20160803

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells • FF
1. Well Contractor information: f FC " iR,-_
Christopher D. Hedd��:n iJivisiolinfYa'aterR.;�nurt^�ic
Wel; Contractor Name S E p 1 2 2016
2044-A I
NC WelI Contractor Certification Number
Hedden Brothers W6,11 Driilt
Company ]+lame
2. Well Construction Permit #: W 101004.36
List all applfcable ivell pernrits (l,e. County, Srale, Variance, lr#ecdou, etc.)
3. Well Use (check well use):
water .�uppq
C7Agricultural
0municipallPublic
[]Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
Cllndusiria!/Commercial DResidential Water Supply (shared)
ElAquifer Recharge
❑Groundwater Remediation
ClAquifer Storage and Recovery
OSaliuity Barrier
❑Aquifer Test
LiStonnwater Drainage
ClExperimental Technology
❑Subsidence Control
5Geothermal (Closed Loop)
❑Tracer
4. Date Well(s) Completed: 8-2- r 6 Well l[V#
5a. Well Location:
David Williams
rat iIitylowuetNamc rucility IDIi (if applicable)
547 Burl Lane Cashiers, NC 28717
Physical Address, City, and Zip
Jackson 7562-32-6894
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or deehnal degrees:
(if well field, one Iatdlong is sufficient)
35' 11.5806 N 83' 135442 W
6. Is (tire) thewell(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: UYes or LINO
Ifihis !s a repair, fill out known well wastructlon lufarmation and explain the nalare afthe
repair under #21 remarks section or on the back of fAis farm.
S. Number of weals constructed:
For nudtipta injection or non -water suMv wells ONLY with the saxte construction, you can
submit one form.
9. Total well depth below land surface: 8@ 150 (fit.)
Formultiple wells list all depths If dfflerew (example- 3@200' and 2Q100)
Ia. Statie water level below top of casing:
If niter level is above easing, ase "+"
11. Borehole diameter: 5 (in.)
12. Well construction method: Rotary
(i.e, auger, rotary, cable, direct push, etc.)
For iaternal Use ONLY:
438591
Wt><Tl;1t ZONES.
FROM TO DESCRIPTION
fit. ir.
I3.:Q:i3iElttyA9 _' muito"cased.Wells U&'; urn
FROM TO DIAMETER THICKNESS MATERIAL
it. ft. In.
. f lilt CASII4G�:a :..�'tls G. otllerrnal clade}i .prl
FROM TO DIAMETER TH[CKNES$ MAT$RIA
0 n• 600 n• 1 In, ❑R-11 H©PE
0 ft. 600 n• 314 In. QR-11 HOPE
' i7� f3LRE
FROM To DIAMETER SLOT SIZE THICKNLSS I MATERIAL
ft. ft. in.
R. ft, in.
FROM I TO MATERIAL EM LACEMENT METHOD & AMOUNT
0 n 15() fit TGI Prol-ite pumped & trim mied
n• I Powertech 1900 gallons overall to
ft. Ir Benonits ensnare 1.0 conductivity
ix-sA O V1 L PACK fs livable
FROM To MATERIAL I RMPI ACRMENT METROD
fit. h.
.,.ZO,:DW LING LOG attaea:aadia Ila . ticefs iE ecesa
FROM TO DESCRIPTION color, ItiLrdoeM avlllm& Uph groin jplM etc. ,
0 30 n• clay & sand
30 n 150 fir granite
It.
!t. fit.
I't. rt. `��: � � - - .��� � fir•-.
SEP
Er
fir, fir.
fG fit.
x1:
22. a tiffcation:
6-3-16
g re o enified Well Contractor Date
By signing this form, I hereby cere jv that the well(s) was (were} constructed fin accordance
with 15A NCAC 02C.0106 or IBA NCAC 02C.02,00 Well Construction Standards and that a
copy of this record has been povided to the ivell owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You nifty also attach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
24a. For All Wells; Submit this form within 30 days of completion of well
construction to the following:
(fir) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
24b. For Inlection Wells ONLY: In addition to sending the farm to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield m Method of feat: 24c. For Water Supply &_Injection Wells:
tgp ) Also submit one copy of this form within 30 days. of completion of
13b. Disinfecdon type: Amount: well construction to the county health department of the county where
constructcd.
Form GW-1 North Carolina Dapnrtmant of Environment and Natural Resources — Division of Water Resources Revised AugWt 2013