GW1-2022-07533_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW 11 OHM For
For Internal Use Only:
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DE$l;[i(pnON
2187-A I o f4Iasi It �
NC Well Contractor Certification Number ft. ft f
I5.OUTER CASIItG 'or
mntthetsed wells OB LII+iER(1i abie
Hedden Brothers Well Drilling, Inc FROM To DIAMETER THICI&CMUS MATZtWL
Company Name I ft. ft in.
q/��/ I6.L11NER CASING OR TUBING eoMermat doseddoo
I.Well Construction Permit#:�.�f 0 1-o?0 9 7- Q-1/1&0 to% TO DtAmptizR TrttCtavess <sATL1tL�L
List all appllrable rrr(/construction pernurs(.a WC,County.Stares Yarfance.etc) � R. ft. ln.
3.Well Use(check well use): ' tt. I 8 ft. in v
. 1 ATE
Water Supply Wetl: 17.SCREEN
Agricultural FROM TO DWIETER SLOTSIZE TFDCCtOiFSS MATERI.IL
IS.
�MunicipaHPublic fa ft. in.
Geothermal(Henting/Cooling Supply) Residential Water Supply(single)
ft. ft, ic.
IDdustriaUContmetcial Residential Water Supply(shared)
FROM
GROUT
In lion � FRObt TO MATERIAL EAIPLaCEil1E\ThIETHOD&A.\IOCiAT
Non-Water Supply Weil: � ft• � zo R � a I Pumped
Monitoring [3Recovery R. ft.
Injection hell:
Aquifer Recharge 00roundwatcrRcmediacion R I ft.
Aquifer Storage and Recovery Salina Barrier 19.SAND/GRAVEL PACK It a IIeable)
tY FROM TO auTEttuL E�rrLACEatti�zalETxoa
Aquifer Test O'StorrnwaterDrainage ft. I ft
I
Experimental Technology Subsidence Control ft. m `
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attacfiladdttionai sheets if accessary)
Geothermal(Heatin Coolie Return) � Other(ex lain under#21 Remarks) PROM TO !DESCRIPTION rtroior.h.,daen,mnhoek n>ta ere t
It. 1 4 8
ft clay d sand
4.Date Well(s)Completed: Well M# granite
Sa.Well Location:
�o�trran ��QCIL fr. rt. i ' V
Facility/OwnarName Facility IDd(if applicable) I ft. i R.
bt.4t/0 Pi'MA i4.ro., J;,K_ ,Ile %6_ �87�3 t� r,. -
Physical Address.City.and Zip r, i ft.
JAC956" TS1.9-rl I-r7873 � 21.R1iSIARKS
County Parcel Identification No.(PIN)
5b.Latitude and Iongitude in degrees/miautee/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
35° iA.364 N 0830 0185-3 w G L �
6.Is(are)the wells) Permanent or MITemporary Signature of Certified Wclt Contractor Oa
By signing this fornz.1 here&-cert6-that z zrell(sl,vas(urrr)constructed in accordance
7.Is this a repair to an existing well: r1 Yes or No with 15.4 NCAC 02C.0100 or ISA NCAC 0?C.0200 Mell Construction Standards and Uatt a
Vh&it a rrpafr,fd1 out.nett zvrll construction injormaifon zalesplain the nawre ofthe copy ofthis record has been proWded to the isr11 onner.
reovir under 921 nrnarksrection or on the back ofNtisjomz. 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 i W-1 is needed. Indicate TOTAL N IvIBER of wells construction details. You may also attach additional pages if necessary.
drilled._ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a,�D A) Z4s. For All Wells: Submit this form %vithin 30 days of completion of well
For maltfplr arils list all depthr ifdfi fermi irsamplr-3Q300'andd 2@100') construction to the folIowintg.
10.Static water level below top of casing: 105 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level it above easing,use—t" I617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter:_ 24b. For Iniection Wells:. In addition to sending the form to the address in 34a
above, also submit one copy of this form Within 30 days of completion of well
(Le Well conry,cable, method: � LC,� construction to the foltotiae:
(i.e.auger,rotary,cable,direct push,etc.)
b-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pm) OZ0 Alethod of test:: 24c. For Rater Suonh•S Insertion 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: l-t :amount-. L completion of well construction to the county health department of the county
where constructed.
Fonn G\V-I North Carolina Department of Enviranmcn;z1 Q-:Ih•-Diction or%eicr Rcsoaxc Rc.ised 2-+=-1016