GW1-2022-06709_Well Construction - GW1_20220712

- I •-:_-_•PrI�t�Forn
WELL CONSTRUCTION RECORD (OW 1) For Tntemal Use Only {
1.Well Contractor Information: f
Russell Taylor 14.WATER ZONES
Well Contractor Name FROMM I TO DESCRIPTION
2187-A f`' 85 r` 0-
a=1ry fL /1B fL
NC Well Contractor Certification Number I ! of O
I5.4tITER CASING for multi-cued wells ORLIlYER(If a eabie)
Nedden Brothers Well Drilling, Inc FRO-1 TO DIA-iETER THICtCYESS MATERwL
Company Name
ft. I fL I in.
e1� A e� I6.DINER CASING OR TUBING eotheltaal eloseddoo
2.Well Construction Permit ir: „lCbr -d 1031-q- la 84 FRo•1 I TO DL1AtETER rxtclGYFss I ATERIAL
EW all appilcable trcll carrslntetion pen7nuts(-e-WC,Coturty,Start Yarfance,etc) 0 n• U fL j O In. C
3.Well Use(check well use): 1" I r70 fL 10 tn. I 1
8 STEEL
Water Supply Well: 17.SCREEN
fl20M I TO DIAMETER I SLOT SIZE THICILNTM -MATERIAL
Agricultural E]Municipal/Pubiic
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft, ft. I ia.
Industrial/Commercial Residential Water Supply(shared)
I&.GROUT
MITI fi0n FROM I TO I MATERIAL I E1tPLACE IENT-IETHOD S A.NIOLrlyr
Non-Water Supply Well: ft. I 20 R• I a�e=a x r<a I piattped
Monitoring ORecovery fL CL
Injection Well:
Aquifer Recharge �Grouadwatcr Rcmediation
Aquifer Storage and Recovery 19.SAPID/GRAVEL PACK if a olieable)
q g ery 0,SalinityBarrier FROM To SLITERLLI EMPLACENE\T-NIETHOD
Aquifer Test 0-StormwaterDminage
Experimental Technology Subsidence Conco! ft. I ft.
Geothermal(Closed Loop) 0-Tracer '0.DRILLING LOG attach additional sheets if aecessa )
Geothermal(Heatin COoling Retum) Other(explain under#21 Remarks) E?to-t I To nESCRIPTION(color.hardness.soiltrock MA gmin sir(.etc.)
ctay a sand
4.Date Well(s)Completed: �l- Well ID" 0 fr- I fL
Sa.��Well Location: ,, PfRF i V;
�/UIr1Q.Yfl�Y1 Rli.'� I ft. I ft.
Faccili ty/Owner Nmne C Facility IDR(if applicable) t� Ie f UL 12 2
-Low
Cl ' A
:,Vt+a ty
1
Physical Address,City.and i ft' I I ftr3 I••"; i ti 1^�, n t h. a •�,c�:'yt_
15 ly9-5b-8(07cR 1 31.RE-L4RKS
County Parcel Identification No.(PIi
5b.Latitude and Iongitude in degrees/minutesiseconds or decimal degrees:
(if well field,one int/iong is sufficient) 22.Certification:
36"' 18. 171 0
f�83 d8_aJB W 30 �
6.Is(are)the ttell(s) Permanent or Temporary SioatureofCerified Wall Contractor
Date
'!� By signing tins farm,1 hereby""'J,anon t ur11(s)was(weir)constructed in accordance
7.Is this a repair to an existing well: 0 Yes or No iiitlr 15A NCAC 02C.0/00 or JS.4,VCAC 02C.0200 Well Construction Standards and that a
-/ft/ifs is a repair.fd!out ktrotut Well eanrtt-nerion Prfartnation in the naturr.ofthe copy of this record has been protIded to the aril ouner.
revair under AVI re narizsection oro on rite bacG•ofrhisfomt. 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 OW-1 is needed. Indicate TOTAL NFUMBER of'•ells construction details. You may also attach additional pages if necessary.
drilled:_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Soo (ft) 24a. For 411 Wells: Submit this form within 30 days of completion of well
For multiple hells fist all depths ildderew ekrmnp/e-3Qa 200'and 2Q/001 construction to the following:
10.Static water level below top of casing: F�� (fr) Division of N;tater Resources,Information Processing Unit
iftrater!oval is ahove Caring,axe"=" 1617 NIsil Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: L (ln.) 24b. For Iniection Wells:- In addition to sending the form to the address in 24a
,��Lct apace, also submit one copy of this form'ithin 30 days of completion of well
12.Well construction method: construction to the foll
t� J VJ ovvia
(i.e.auger,rotary,cable,direct push,etc.) s:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) D tN3ethod of test: 24c.For Rater Suooh•'&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: L t_d a completion of-,veii construction to the county health department of the county
Where constructed.
Form G1Y-1 North Carolina Depanrent oflinviran-:ntai Q.'I;y-Di s:o..-e:V:=ter Rcsou:crs Reused:?�-2016