GW1-2022-07531_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only. PriFlt or
1,Well Contractor Information:
Russell Taylor
14 NATERZONES
Well Contractor Name FROM TO DtSCR[PII01\
2187-A i "• ft
fc.NC WcIi Contractor Certification Number IL
=EMING
lti-used VT&- OR LINER Qf able Hedden Brothers Well Drilling, Inc IAMLTER THJ0%..iFSS MATP
ILIAL
Company Name q in.
2.Well Construction Permit#: Of -dQV 19- 7 18� eothermal closed-iao
FROM7nJ
TO D2A.atErER THTCEOMSS NlATERiAL
Lest all applicable bell ransawtlon permits(r.a.L7C,Comely,State,Variance,eta) �. it. /_ In,
3.Well Use(check avell use): 1 f fa tv in.
Water Supply Well: 17.SCREEN
Cultural FROM TO DtAhtEl'ER SLOT SIZE TFIIC[�'FSS 1TATERLAL
Agri C)Mtuticipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) ft. ft. is I
i&GROUT
Irrigation FR01i TO MATERLaL EAIPLAC&aiE.\T1[ETIiODS.ilI0L5\T
Non-Water Supply Well: ft. I 20 n• I aaeeaee�,, I atanDed
Monitoring Recovery rt.
fL
ejection Wall:
Aquifer Recharge DGroundavatcr Rcmediation tL I iL
Aquifer Storage and Recovery19.SAD1D/GRAVEI,PACK ita lieablel
�SaliniryBarrier FRObt TU .SfATE1rLtL E.afPLAGEie2E\TIIETHOD
Aquifer Test E3StormwaterDrainage tc. ft.
t
Experimental Technology MSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRIL I.I:\G LOG attach'additional sheets if neeess
Geothermal(Iieatin Coolie Recum) 'Other(ex lain under#21 Remarks) FROM( TO (DESCRIPTION icotonhardnemson/rock nslrrrem)
i^ fr. D- ; clay 6 sand
;r
4.Date Well(s)Completed: 7 8 Dad Well ID i l�
I ft. ft. I:granite f'y+
Sa.Well Location:
+ groom ltbl�'�rcelrTrceFuest ; e. ft.
Facility/O Namc Facility IDd(ifapplicable) ft. I ft, I -
.34O 'R783 a. i'. Ifif%f �:ac� ran^sue; -
Physical Address,City.and Zip 0 Jfr. i ft.
SIA�Ydewf le tw1r /$I�-�p� �pv�9 21.RENrARM
County ParcelFdendficadon No.(PIN) P-
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
LifwaU field one lat/loag is Sufficient) 22.Cer•tifiCatiOn:
356 116.B 1(1 N o 83' o►.9 85 w2�a�� ,Q aos
6.Is(are)the well(s) Permanent or DTempoMry Signature of Certified well Contractor Date
By signing this forme.I hereby cerfify�that t rrrll(s)was(is-err)comiructed in accordance
7.Is this a repair to an existing well: n yes or No r,*11.5.4 NCAC 02C.0100 or 1SA NCAC 02C.0200(Yell Construrtlotr Standards•and that a
/f rlt@ is a repoir,fdl our knorin tve/l eon iruetion information rr?esplain the nowre..ofthe copy of this record has been provided to the irell oaner.
repair under 921 remark seuion or on the back of dtis form.
13.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 1�r l is needed. Indicate TOTAL NILRvIBER of vmlls construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: f (fL) Z4a. For .411 Wells: Submit this form within 30 days of completion of wall
For nmlhjtlr wells list all depths ifdderew(example.3@200'and 3Q100') constriction to the following:
10.Static water level below top of casing: ll VL (ft.) Diaision of Water Resources,Information Processing Unit,
(ftvatnr level is above casing,use'+' I617;NIaii Ser-vice Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b. For Iniection\Yells in addition to sending the form io the address in 24a
n � above, also submit one copy of this form Mthin 30 days of completion of well12.Well construction method:._Lt 1
(r.e.au p r +— ■ construction to the folloaatit
gee,rotary,cable,direct push,etc.) � r-
Division of Rater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (� 1636 Nlail Senice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l J Method of test: 24c.For Rater Sunala•I Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form mithin 30 days of
13b.Disinfection type: amount: 1 completion of well consauction to the county health department of the county
where constructed.
Form Gw-I North Carolina Department of En%iramontal QY liry-Diysio'. RCSOa:CCs Rctised 2-=•2016