GW1-2022-08194_Well Construction - GW1_20220516

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WELL CONSTRUCTION RECORD (GW 1) For Internal Use Only: --
1.Weil Contractor information:
Russell Taylor 14.WA7ERZONES
Well Contractor Name FROM I TO DESCRIPTION
2187-A �L15 "' tt1LL 0 "' -/&Ip
NC Well Contractor Certification Number �IF10 fi' T1 IL
1S.OUTER CASING for mu(tlktsed wells OR LINER(If a livable
Hidden Brothers Well Drilling, Inc FROM TO DIAMETER mICK.YESs MATERIAL
fr. ftL
Company Name
' t n4�INER CASING OR TUBING eothermm et-a-ioa
2.Well Construction Permit bi f' of '• -1 OQ FROM To I DuatETER rincl.•NFcs MATERUL
Lest all applicable it-ell construction peialits(.a UiC,Cotutty.Stare.Madance,etc.) 0 ft. I /_ iL Ia.
3.Well Use(check well use): ft. & IL in I � Elm
Water Supply Well: 17.SCREEN ,
Agricultural FROM TO DIMIEJER SLOTSIZE THICK4NESS MATERIAL
[3Municipal/Public ft. f4. U.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. y in.
Industrial/COcnmercial OResidential Water Supply(shared) is.GROUT
Irrigation FROM I TO I MATERLIL I EttPLaCEBIM-rN[EiHODS,LvIOL°A'T
Non-Water Supply Wel1: ft' 20 R- I R,;r,r,'s, pumped
Monitoring ORectivery
Injection Well: I
ft Aquifer Recharge [)Groundwater Rcmediation IL
Aquifer Storage and Recovery I9.SAND/GRAVEL,PACK ira linable
C��;;J Salini tYBarrier FROM I TO tIATEPJAL I E.stPL.ACEME.\7METHOD
Aquifer Test 0-Stormwater Drainage ft. tL
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRII LIi!G LOG attach additional sheets if neeessa
Geothermal(Heatin Cooling Return) ' Other(ex lain under Q1 Remarks) FROM TO DESCRIPTION icalar.hardness.wlUrack type gr2in sim etc.)
0 ft. I fL I clay&sand
4.Date Well(s)Completed: I S Well ID a. 1600 ft. I gra6;ta
Sa.Well Location: R. ft.
i
l.SX1n;3 iP_C Q)eass fr. I
Facility/OwncrI.Ame Facility(D4(ifapplicable) ft. i ft.
Liftle 61bow m-l".Qd. LAXC.7on,,� . a8747 ft ft.
Physical Address.City,and Zip U fr. I ft. I InforA-i8 Son rC•%�its3t g
ra.s vclni 85,3.15.8 g76:� 21.REiiLARKS
BiNGABOG
County Parcel Identification No.(PIN)
1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one IaViong is sufficient) 22.Certification:
35° 1 164, iY osao .!a.511 W
6.1s(are)the well(s) Permanent or OTemporary Signature ofCcttificd Well Contractor Date
By signing this form.I herebr cer"A.thatA.r11(SJ Was(Ire e)eoartrueted inaccordance
7.Is this a repair to an existing well: Yes orP.1explain
No with 13A NCAC 03C.0100 or IS.d NCAC 0 .0?00 Yell Construction Standards and that a
jrhis it a repair,fdl out knot well construction information the nature.of the cops'o(this record has been provided to the well owner.
tepuirunder 921 remarAT recdon or an ire bachofttisfornt. 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 GW-i is needed. Indicate TOTAL NIUMBER of neIls construction details. You may also anach additional pages if necessary.
drilled:_1
/� SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: 140D (ft.) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtTerent 6waimple.3@260'annd 2@100'I constriction to the following:
10.Static water level below top of casing: (ft.) Division of Nttater Resources,Information Processing Unit
/!'water level is above easing,use"+" 1617 Mail Sem icIa Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: in LiJ f construction to the following:
(Le.auger,rotary,cable,direct push,era)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 13 ,x•Iethod of test: ukJ 24c.For Water Suoph'&Injecrion Weiis: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ` Amount: completion of well construction to the county health department of the county
where constructed.
Form G%V-I Nortls Carolina Department of Environmental Quality-Di.sioa o:Watcr Rcsources Revised 2-2-1-2016