GW1-2022-08201_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD (GW-1) For In emal Use Only:
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2187-A 10 6 ft. /LL/LLa
NC Well Contractor Certification Number 8 ft. 73 ft.
Hedden Brothers Well Drilling, Inc FRO OUTER Ts11v- form DIAM TER- pTHt IICius¢ MATERIAL
Company Name R• In•
n A 2.Well Construction Permit : n� � -// 16FRotit.IaYNER CASING OR INCTQB eothermal clased4nnal
�ldt ( d To DUMETFR I Tttrct..-vEss I -VTATERL41
List all applicable rrell ronsiniction permits d.a U)C,County.State,Variance.etc.) 0 ft. I fL In. •1®Q 66L
3.Well Use(check well use): fL I is in. OCJ
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOTSiZE THICJMESS MATERLIL
!ri OMunicipal/Public
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
IndusMal/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL E1tPL.4CE,*,ln7b(ETHOD S A.IIOL°NT
Non-Water Supply Well: '0 ft. I 20 fL .an v_, I pumped
Monitoring Recovery ft.
injection Well:
Aquifer Recharge DGroundwatcr Rcmediation fL I tL
Aquifer Storage and Recovery19.SAIND/GRAVEL PACK if applicable)
�Saliniry Barrier FROM To NL►TERL%. E?tPL cFmmmmETHOD
Aquifer Test 0-StorrawaterDrainage ft. I m
Experimental Technology Subsidence Control fr. I ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if neeessa )
Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) FROMI To DESCRIPTION Icolor,hardness,sa111roek a rMin sirs cte.I
D I fL I clay 8 sand
4.Date Well(s)Completed: Well ID4 r7l, ft I OQ n I granite
Sa.Well Location: � R. ft.
to W 11sa1 Fl ecli C'-1 ne • ft. R.
Facility/Owner Name Facility 11)m(if applicable) ft, ft. l
M 114WY 10?tJ l ll}sN1f2.S -16717 rt ft.
Physical Address,City,and Zip ft. i ft.
i
757a—M-J1sl =1.REiF1ARKs
�et,Gsoa Cl.aT Dt�►Q/BOQ . 9110
County Parccl identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1000ng is SutTicient)
22 Certification:
3 6° D&.919 ;v b83° DIP-410NV i J4 ae
6.IS(are)the wells) Permanent or OTemporary Signature ofCerrified 1Vcll Contrat[or Date
By signing this form,l hereby eertif5•that m tar/l(s)teas(ittror)constructed in accordance
7.is this a repair to an ex°sting well: [3Yes or No tttdi 1SA NCAC 02C.0100 or)S.l,VCAC O2C.ozoo Nell Construction Standards and ilia/a
1f(his is a repair,fill"'rtkno 7r_1vel/construction tnforntation m�esplain the nottere..of the, copy ofthis record has been provided io the aril onuer.
repair under#21 rmnarls seerion-or on the back ofdrisforr.
23.Site diagram or additional%yell 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 1�R'-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: qq SUBMITTAL INSTRUCTIONS
d
9.Total well depth below land surface: DD (ft.) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple ttrl/s list all depths itdierent(trample-3Q200'and 2@100'1 construction to the following:
10.Static water level below top of casing:_�Q (ft.) Division of Water Resources,Information Processing Unit,
Itivater level is above caring.use'_' 1617 Mail Service Center,Raleigh,NC 2769 9-1 61 7
11.Borehole diameter:,� (fn.) 24b.For Inieetion Wells. In addition:o sending the form to the address in 34a
n � construction
also submit one copy of this form Within 30 days of completion of well
12.Well construction method: con
c 1 f� struction to the following: j
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY W//��ELLS ONLY: Q •� 163611ail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) SQ it•Iethod of test: WKJ 24c.For Water Suooly S Iniection Wells: 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: L d completion of well construction to the county health department of the county
where constructed. j
i
Font GNV-I North Carolina Department of Environmental Qu..lia•-Division ofll'accr Resources Rcvised 2-22-2016