GW1-2022-07529_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: PrlM Fom
1-Weil Contractor Information: l
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2187-A i ft. 5 ft
ft. ft
NC Well Contractor Certification Number 15,OITTER CASING for multt•c�,ed wells OR LTNER ftf cable)
Hedden Brothers Well Drilling, Inc FROMI To DIAMETER TH1c 04M MATERIAL
Company Name ft. I ft 1 In.
1.Well Construction Permit#: t��—o�LD 19—9— 117 rg
fltONFTNERCASINGORTUB16. �G�ermalTHTCt4NM MATERIAL
LW all opplleable=11 trontmtetton permits ft.a.WC,County,SW4 Variance.eta) i. 0 R. I R. %2to „ in. ��
3.Well Use(check well use): I 11- I ft U/ hL a
C� 13-re
JAgricultural
ter Supply Well: 17.SCREEN
FROM TO DIMIETER SLOTSIZE TRICl01'V4= 1rATERAL
DMunicipal/Ptrblic ft ft. in.
eothermal(Heating/Cooling Supply) OResidentiai Water Supply(single) ft, ft. in.
dustrial/Commercial Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO AIATERL L I EMPLAMIMM METHOD S AMOLT'T
Non-Water Supply Weil: ft I 20 fl. �,.. , pumped
Monitoring DRecovery ft fc. I
Injection Well: ft I ft 1
Aquifer Rochargc DGrouadwatcr Rcmediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK if applicable)
ty FRONT TO MATERLIL I LN1PLACEME\TMErHOD
Aquifer Test 0,StormwaterDrainage ft. I it.
Experimental Technology OSubsidence Control ft. I ft I
Geothermal(Closed Loop) 0-Tracer 20.DRILLING LOG attacb,additional sheets if necessary)
Geothermal(Hearin Coolie Return) ' Other(ex lain under#21 Remarks) FA0�1 ro DESCRIPTION icolor.hardness,sciur L n girt dr.)
r� 0 ft- fL I !clay d sand
4.Date Well(s)Completed: i a0 O�{°a� !Veil ID# i ft. I ft granite
52.Well Location: I R. ft.
1�w,4h+ 8ioolri Wof�'Cfazlc T► Fa►,.l Ft. ft. j
Pu
Faei' /OwnarName Facility IDd(if applicable) I ft. I fr.
340 &&L 0ounti ed- i r� tt. I, _ 20 2
Physical Address,City.and Zip 1 Ft i ft. !,
.�hcx sty► Couur4 21.RE,IARKS
County Parcel Idcntificarion No.(PIN)
5b.Latitude and Iongitude in degrees/minutesiseconds or decimal degrees:
(if well field.one lat/tong is sufficient) 22.Certification:
35° ►�. rw .l 0830 W. a3o w � � a� a a�
6.Is(are)the tteli(s} Permanent or 07remporary Signature of Certified Wcil Contractor Date
By signing this form.1 hereby certify that t twll(s)tras(wor)coaTtrueted in aaordaner
7-is this a repair to an existing well: [)Yes or No t,dtlt!SA NCAC 01C.0100 or IS.d VCAC 01C.01o0 well Construction Srandw*and thm a
lrhir is a repair,fdl out knonn,veil eatutruetion information A.-explain the nature gr1he copy ofthis record has been provided to the aril owner.
repair under 921 remarls section or an the back of this form.
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 pace to provide additional wellsite details or well
construction,only I GW-1 is needed. Indicate TOTAL ArUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /M0 A) 24s. For .411 Wells: Submit this form within 30 days of completion of well
For multiply wells list all deptlu Ffdiffermi(erample-3@200'and 1Q100') constriction to the following:
10.Static water level below top of casing: Jo (ft.) Division of Wafer Resources,Information Processing Unit,
if water lave/is drove casing,use I617 Mail Senice Centex,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Inieetion Wells In addition to sending the form to the address in 24a
L above, also submit one copy of this form nithin 30 days of completion of well
12.Well construction method: Q 1 1T construction to the followine:
(Le-auger,rotary,cable,direct push,etc.) U
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ML Yield(gpm) 1 Method of test 24c.For Rater Suooiv f dniection 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: rl Amount: completion of well construction to the county health department of the county
wheie constructed.
I'
Form Q%V-I ?north Carolina Department of Envlronm.wal Qe lky-DNi ion.oft`:-icy Rcsou ccs Revised 2-"-1016