GW1-2022-08204_Well Construction - GW1_20220516

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Russell Taylor 14.WATER ZONES
Well Contractor Name FROM TO DESCIMMON
2187-A 3,15 t`" -80
NC Well Contractor Certification Number /{,�6 ft. R O pG
is.OUTER CASING formultf-eaaedwe11s00✓RLINEA(Ha cubit)
Hedden Brothers Well Drilling, Inc FROM TO DIAMETER THlctc M MATERIAL
I ft. iL in.
Company Name
` I r/�n�- ^�,- 16.INNER CASING OR TUBING(eothermal closeddoo
N
2.Well Construction Permit 0: GY 63& FROM To I DW%TETER I THICK-=S I MATERIAL
Un all applicable uell Wnstntetton permits(.a.L7C,County,State,Yarfance,etc.) 0 n it. ! in. PVC
3.Well Use(check well use): 018 it. 1,46 it. in. 88 ,
Water Supply Well: 17.SCREEN
FROM TO DLWETER SLOTSIZE TRT1-V\ESS &?A7ERLiL
Agricultural E)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft is
Industrial/Commercial Residential Water Supply(shared) LAGER
;
Irrigation FROM TO MAITERIAL E�IPLACE,NIENT.NtETHOIIS.I..IIOL1T
Nan-Water Supply Well: 0 R. 20 2 am:rsaerrta I pumped
Monitoring Recovery rL h.
infection Well:
ft. � tL
Aquifer Recharge oGroundwatcr Rcmediation
19.SAND/GRAVEL PACK ita lieable)
Aquifer Storage and Recovery Salinity Barrier FROM TO �IATERLtL ENIPLAMIF-SrMETHOD
Aquifer Test O-StormwaterDrainage It. tc
Experimental Technology Subsidence Control ft. ' ft.
Geothermal(Closed Loop) Tracer a DRILLING LOG atsacb additional sheets if necessary)
Geothermal(Heatin Cooling Retum) Other(ex lain under�21 Remarks) t•R70 To DFSCRIPTIO\ colon hardness.soittrock tl e tam srze,etc.)
cloy S sand
4.Date Well(s)Completed: 1 t>R Well ID4 I fc 11000 t' ( gtanae
Saa.,Velll�Location: /1
_L x& T�CQ,LNQM l MAY 1 �, 2022
Facility/OwncrName Facility IDR(if applicable) ft. ft.
�& R.lid e- T as'7Aw7 ft. rt. lnforvr, n r:Rcmowig nw
Physical Address,City.and Zip Q� }� Co f ft. I
�C1�1SU �. COWIft/ Q;J�V" qpp -11.REbIARKS
ou�County*
Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
114 ©8a0 ,58. 687 W 1 = as
6.1s(nre)the well(s) Permanent or OTemporary Signature of Certified Well Contactor Date
By signing this form,l hereby eerrify that t ur1101 Ims(sere)conrtnicted in aceardance
7-Is this a repair to an existing well: nYes or No pith 15d NCAC 02C.0100 or 15A NCAC 02C.0100(fell Consimctian Standards and that a
!f/his is a repair,fell our know»tvrll eoiutnretion injarn 'Ion ta�ecj loin the nature ofthe copy ofthis record has been provided to the nett owner.
repair under P21 reaarl3 section or on rim back of thisjonn.
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 1�W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTION'S
9.Total well depth below land surface: Joao (fL) 24a. For A11 Wells: Submit this form within 30 days of completion of well
For multiple urUs list all depths ifdWerenl teramph-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: goo (ft.) Di'ision of Water Resources,Information Processing Unit,
ifrvater level is above casing,use'-" 1617 Mail Sen i zce Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection 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: IQ LiJ construction to the following:
(Lt.auger,rotary,cable,ditect push,etc.) �—
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_ 3�- Method of test: 24c.For Water Suopiv&Iniection Wells: In addition to sending the form to
{{�� the address(es) above, also submit one copy of this form ttithin 30 days of
13b.Disinfection type: l F 1 Amount: �d completion of%veil construction to the county health department of the county
where constructed. i
Fonn GW-i North Carolina Depanmcnt of En%iranm.ntal Qualiry-Division o"Watcr Rcsi
ourccs Revised?"-2016
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