GW1-2022-07698_Well Construction - GW1_20220811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: .'
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
FROM TOI DtSCRIPTioN
me Well Contractor Na j O Ct. ft
2187-A 1 ft. i>.
NC Well Contractor Certification Number 151 OUTER CASinG forvltt-cased wells OBLIlYER a m abie)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER TIUci -O DtrtlPRtAt.
fr. ft.
Company Name
^' n 16.INNER CASING OR TOBING er eothmal closed-too
2.Well Construction Permit#: ��f I-OZ 13 1p'/- 9-111 O FROM I TO DLIONIErEn I THTCELVESS MATERIAL
List all applicable aril constmelton permits(t.a.UIC,County,State,Vartarwe,etc.) '. 0 R. I IL {n. `'
3.Well Use(check well use): ft. I 8 ft. in.17.SCREEN
. ' QrY�E '
JIrAgricultural
terSupplyWell: FROM TO DtMIETER SLOT SIZE TMCKTBSS DIATE%AL 0Municipa.VFublic ft, ft. in.
eothermal(Heating/Ccoling Supply) JaResidential Water Supply(single) ft. ft.ndustriallCommereial Residential Water Supply(shared) I&GROLTP
lt t10n FROM TO �StATERL L I L1IPLACEAIEITAIETHODS.L-tfOL+1T
Non-Water Supply Well: 0 ft zo an,_arrr+. I pumped
Monitoring [3Recovery fL ft.
ejection Well:
fa I ft. I
Aquifer Recharge DGroundwatcr Rcmediation
Aquifer Storage 19.SAND/GRAVES.PACK if a Ueablel
Aq ' rage and Recovery �Saliniry Barricr MOM TO JIATEAIAL EXPLACE6tE.YT NIMOD
Aquifer Test E3Stormwater Drainage ft. ft I
Experimental Technology Subsidence Control rr. tt
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nteessaryl
FROM TO DESCRIPTION(color.hardoeaaorr/roek a n Am em)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) C fr. I ft
clay is sand
4.Date Well(s)Completed: '� Well ID;f * 1,25Q
ft � granite
5a.Well Location: I Ct ,.°
n _"gg
Ct. ft. I t�Q e- t °
Wo.rren J61ft L
i
F mc aeility/OwnarNa /1 Facility IDS(if applicable)
Zft• ft.
4-07/0 'ArwS@ Cab ior n K .99��3
Physical Address./City.and Zip ft, i Ct. ,I {fltGipfi3iAL!'1r^v
L�ACX5&A l euwl ni r7 I-78 r133 21.RBh1ARXS t '
Counry Parcel ldcndficarfon o.(PI\)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field one lot/long is sufficient) 22.Certification:
350 083° O'7. 853 W d40
,�,( Signature ofCenified Well Contractor Da
6.is(are)the a ell(s)�@1 Permanent or Temporary
T�+ By signing this Jornt•1 herrbr certify that r r rll(sl+vas hvem)eoartrueted in a=ardaner
7.Is this a repair to an existing well: I3 Yes or No ,*Iz 15.4 NCAC 02C.0100 or IS.•i h'CAC 02C.0200 Bell Coarmtctlan Standardr and that a
/ftliir is a repair•fdl out knon7r%veil eonstruc on information the nature of the copy grzkv record has been provided to the,rell ou7rer.
repair under e21 remanlasectiat or on the back ofrhisfamz. 23•Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Gevprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only l;W'l is needed. Indicate TOTAL NUMBER of wells
drilled: 1- ��++ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �JQ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For muldplr++rl&list all dept?a i(difjrrew tixamplr-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (fr.) Division of Water Resources,Information Processing Unit,
lftvater level is above caring.use••_'• 1617 AIsil Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter. i2 (in.) 24b. For Iniection\i'elis: In addition to sending the form to the address in 24a
� L� above, also submit one copy of this form Rithin 30 days of completion of well
12.WeU construction method: T) construction to the following:
Ci.e.auger,rotary,cable,direct pusk etc.) v
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY NYELLS O,ILY: 4 1636 ilIsil Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0(0 A3ethod of test: Lae 24c.For Water Supply&Injection 31elis: In addition to sending the form to
the address(es) above, elso submit one copy of this form within 30 days of
13b.Disinfection t<•pe: amount: I completion of weli construction to the county health department of the county
where constructed.
Revised 2-2-1-2016
Form GW-I North Carolina Department ofHnvirazim.ntal Q•.:aliw-Diaior.o:t s.cr Rcsowccs