GW1-2022-07532_Well Construction - GW1_20220811

PrInthrrr
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
Russell Taylor 14.WATER ZONES
FROM I TO I DESCRIMON
Well Contractor No= ft. ft
2187-A ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for maltt-Cued wens ORLITiER Qf aDid
Hedden Brothers Well Drilling, Inc FROM Ta DIAMETER
T1ucicvEss MATBRtAL
ft. fL in.
Company Name
qq1 I6.INNER CASING OR TUBING etrthermal closed-too
1.Well Construction Permitor��DA—9— 117 Ba M[FRO To atAMIETEA THTCILVESS atATERiAL
f.[rt all applicable urlf Construction pemlits C iUC,Cotenty.Stare,Variance.etc) I R. I .710 ft. j In. C
3.Well Use(check well use): ft. I ,28
ft UJ Q .
Water Supply Well: FROM
SCREEN U
PP Y FROMI TO DiM1ETbR SLOT SIZE TFIIC[�ESs MiA7ErrUL
Agricultural C)Municipal/Public ft. ft. is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, fa
IndusttiallCommereial Residential Water Supply(shared) 18.GROUT
ltti tIOD E'ROMf I TO I MATERIAL EDIPL�C'EMTi_1TMIETFiODS.i�fOi'AT
Non-Water Supply Weil: ft 20 ft. I asu.;ae,rrs. I pttntped
Monitoring ORecovery R ft
Injection Well: ft. I IL
Aquifer Recharge 00rotmdwatcr Rcmediation
19.SAtM/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM i TO I MATERIAL I F-%tPLAcEbM-r METNOD
Aquifer Test MStormwater Drainage ft. I It.
Experimental Technology OSubsidence Control it. I it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if neeess
FROM TO OFSCRIPTIO%[color.hordnem soUIroek a sim etc.)
Geothermal(Hearin Caolin Return) Other(explain under =21 Remarks) fr. I fL I Nay a sand
4.Date Well(s)Completed: pZ0 p{Do Well ID4 16 ft. I ft. granite
Sa.Well Location:
fr. ft. I' s
�tuiQ`1+ Bioom'wo(#-'l!'tEIC.rYPe-/w'Ml i
Fad i4lOOwnerrNamey ,,yam, Facility IDO(if applicable) ft. i fr.
340 &CIL�' t j eJ- ���dS 9_L..03 ft. re. I -
ft. ft. vr, +3.dC 1 f;JCS.
Physical Address.City.and Zip i I
Pub IL.50r1 CoutJTI 21.RESIARKS
County Parcel Identification No.(PINF)
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(if well field one lavtong is sufficient) 22.Certification:
350 I&. IN N 0830 W. 030 w '7
6.1s(are)the wells) Per nianent or MiTemporary Signature of Certified Well Contractor Date
By signing this force.1 herd-certify'that t r,rll(sl tras(were)coartructed in accordance
7.Is this a repair to an e=isting weU: [3Yes or No ufth ISA NCAC 02C.0100 or ISA XY C 02C.0200;Vell Construction Sandards and that a
!#this is a rrpoir.fdioar knotty tvr/1 construction infortnaiian tospiafn the nature ofihe cops'ofthis record has been provided to the ut/l ouster.
Fo t uner rrmarla section or on the back of this famr.
pi d #21
a 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 page to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface. 10M UL) 24a. For .411 wells: Submit this form within 30 do)% of completion of well
For multiple urns list all deptAr ifdiljrtrrrt(rsaurple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: �) (ft.) Division of water Resources,Information Processing Unit,
iftvoter level is about easing.use"_" I617 Nlail Service Center,Raleigh,NC 276 9 9-1 61 7
11.Borehole diameter. (in.) 24b. For injection Weds: In addition to sending the form to the address in 24a
� n above, also submit one!copy of this form within 30 days of completion of well
12.Well construction method: .� - T construction to the following:
CIA.auger,rotary,cable,direct push,etc) v
Division of Water Resources,Underground Injection Control Progratrs,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 A3ethod of test: 24a For water Sunnis &Iniection Wells: In addition to sending the form to
ff the address(es) above.!also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1 completion of.yell construction to the county health department of the county
where constructed.
Form MY-1 ?north Carolina Departncm ofEnvirailm-n;zi Q--liry-Divsior.or\C:er Rcsowccs Revised 2-2-1-2016