GW1-2022-07534_Well Construction - GW1_20220811

Met Fom
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 1 14.WATER ZONES
FROM To DescRipmor
Wen Contractor Name I O It.
2187-A
• 1146 ft. /50 ft.
YCWcllContractorCettifieade°Nttmber 15.OUTERCASING(for -cased ORLINERfIf able
Hedden Brothers Well Drilling, Inc FROMTD DtMtE7ER THicicvEss MtAZIRt)►L
I ft. fL In.
Company Name
MATE
PI"
16.INNER CASING OR TUBING(geothermal closed-ioo
2.well Construction Permit#: ptLaoo-47,7 718-9- I ll ea3 1TtoaT To D A%TE ER TxICILNI ss tuL
EW all applicable well construction pernifts(.a.UiC.County,State.Variance,etc.) I. 0 n I 9 zL 1°' Pvc,
3.Well Use(check well use): _ 1 ft. j ft. 7A . 188 rEE
Water Supply Well: 17.SCREEN
PP Y FROM TO DtMtETER SLOTS17 TFiICI4TE55 MTA7ERLIL
Agricultural C)Muaicipal/Public ft tt. la
Geothermal(Henting/Cooliag Supply) MResidential Water Supply(single) ft. ft. i is
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
Irrigation FROM TO SIATERUL E1IPUCEM ECI MIETHOD&XV10
Nan-Water Supply Well: ft 20 ff �.a +. pumped
Monitoring ORecovery ft ft. i
injection Well; ft I ft
Aquifer Recharge []Groundwater Rcmediation
19.SAND/GRAVEL PACK 1f a licable)
Aquifer Storage and Recovery Salinity Barrier FltoMt TO SUTt:AIAL >:sfPueEMTE�TaI>TTtOD
Aquifer Test O'StormwaterDrainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 0-Tncer 20.DRIMUIX TG LOG attach additional sheets if n
FROM TO DPSCR1PT10%)color.lurdnm.sopttoek a a after tt:l
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) 0 fr.
' clay d sand
4.Date Well(s)Completed: Well ID# 1,39 it. loco tt I granite
Sa.Well Location:
ft. ft. I P NE U
MakveAOL MyCai�.
Facility/OveaaNatnc Facility IDw(ifapplieablle) 1-
ft.
e2'AF >�r�'e b y irG L(Lt�.Q e,. g
OS 8r l 11 r- -
Physical Address.City.and Zip o �n 'r ^r. U�►
J ACX--,oa Ca-wrY Aga, roc't)4+s I �l.REML4RKS n '
County Parcel ldcnditcaricn moo.(PI1)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweQ field one iat/iong is sufficient) 22.Certification:
1�. f7td 21.1 W
I
6.Is(are)the wells) Permanent or Temporary Signature ofCcmflcd Wall Contractor Date
'tr�� By signing this forn,.1 hereby certify that t t.Tll(s)eras(»ire)ean..trueted!n aaaardance
7.Is this a repair to an existing well: Oyes or No brit:S.I NCAC 02C.0100 or ISA NCAC 02C.0200 Nell Consttuedon Standards and that a
!#'this is a repair,fill out knomi wr/l construction information rarsplain the naturr.0.0he - copy of1his record has beert provided to the it-ell ouster.
repair under 921 renarksseetion or on the back ofthisform. 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 artach additional pages if necessary.
drilled: I f1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ADO UL) 24s. For Ali Wells: Submit this form within 30 days of completion of well
For multiplr tt•ells list all depths j/'diluent tintainp/e-3Qa 200'and 2Q1001 construction to the following:
10.Static water level below top of casing: W (fr•) Division of Rater Resources,Information Processing Unit,
Iftvater/ovr!ir above rasing.use"+" 'I61-t INIa i Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._ (ln) 24b. For lniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form nithin 30 days of completion of well
12.Well constructiod method: Q L 1t � /� 1 construction to the follotieing:
(i.e-auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma i il Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ (•Method of test* 24c.For Water Suooiv&Infection 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*-pe: r f1 Amount: completion of well construction to the county health department of the county
where constructed.
form Gw-I North Carolina Deeparment of Enairontrcnt-'Q=uit -Di lion of wztcr Rcsowccs Rctis d?'?-Ai 6