GW1-2022-08212_Well Construction - GW1_20220502

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WELL CONSTRUCTION RECORD (CW-1) For Internal Use Only:
1.Well Contractor information:
Russell Taylor 14.%ATERZOINTS
Well Contractor Name FROM TO DESCRIPTION
2187-A ft.
ft. ft.
NC Well Contractor Certification Number
15.OUTER C.ASMG for mutt(-cased wells ORLINER(If a Ilcable)
Hedden Brothers Well Drilling, Inc FROM To DIAMETER THICILYESS MATERIAL
Company Name
ft. ft j in.
16.INNER CASING OR TUBING eothermal closed-loon)
1.Well Construction Permit#: Mom To I DIAM MR I TBIch'NEss IMATERTAL
L(sr all applicable utrll ronrtntction permits 171A IIIC,Cola,%State.irariance.etc) 0 It. ft. In. • '88
3.Well Use(check well use): ft. tL in ( e
Water Supply Well: 17.SCREEN
FRONI TO DWIETER I SLOTSIZE I THIC&NESS MATERIAL
I
ricultural MMunicipal/Public ft.
othermal(Henting/Cooling Supply) Residential Water Supply(single) ft, ft. I in. I
ustrial/Commercial Residential Water Supply(shared) 18.GROUT
anonM TO SfATERfAL E.IPLAGEAIE\'CIIETHODSA110tWater Supply Well: 0 it. 20 rL pumped
nitoring C3Rccovery
Injection Well:
ft. I iL
Aquifer Recharge �Groundtivatcr Rcmediation
Aquifer Storage and Recovery Salini Battier I9.SAND/GRAVEL PACK ita licable)
ty FROM TO MATERIAL L*IPLACEMIL,r51 O-D
Aquifer Test OStormwater Drainageft. l fc 1
Experimental Technology Subsidence Control ft. I ft.
Geothermal(Closed Loop) Tracer 20.DRiLLL\G LOG(attach additional sheets if neeesso
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks) I FROM I To I DESCRIPTION'teolor.hardness.3ciUroek c. min slm etc.)
clay 6 sand
A&4 Q-4.Date Well(s)Completed: Well ID 8co gra
So..Well Location:
�[� I ft• te•
s1Qr CD11f ion HO.% Go as L IL ft. ft.
Facility/Owner Name , Facility ID0(if applicable) ft.
hers EOM Vi I 1mr. 428717 ft. ft. C
Physical Address,City.and zip ft. I ft. I 7
-IAC950to C OUN Ty 21.REMARKS
County Parcel ldentificarion No.(PIN) u•, af--'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
;r�.r.- •? a'f CSC"i��Ui\
(if well field,one lat/iong is sufficient) 22.Certification:
35.° oto. 8d5 ;v 083 ° 05- 894 W , �� o
6.Is(are)the wells) Permanent or Temporary Signature of Certified well Contractor Da
'f� By signing this farm.1 hereby certify that i rrr//(s)ryas levier)canrtructed In accordance
7.Is this a repair to an existing well: [3Yes or No isith ISA NCAC 02C.0100 or 1S.d NCAC 02C.0209 IF'ell Construction Standards and that a
If this is a repair.fill art[known rvell emrstnretion information_Ailexplainthenatirreq(the_ _ ropy gfthis record has been provided to the mill onner.
repair under i:21 remarkssectiou 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 1 G V-1 is needed. Indicate TOTAL A'UMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1 Q SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V 00 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple uplls list all depths ifdiermt(eramp/r-3@200'and 2®1001 construction to the following:
10.Static water level below top of casing: 81) (ft.) Dirlsion of Water Resources,Information Processing Unit,
Ifwater local is above casing,use'c" 1617:flail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b. For lniection Wellsa In addition to sending the form to the address in 24a
� �'� above, also submit one copy of this form Rtithin 30 days of completion of well
12.Well construction method:!� J
(Le.auger,rotary,cable,direct push,etc.) ` construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: w 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) illethod of test:. 24c.For Water Suonh•8 Iniecton Wells: In addition to sending the form to
rt� f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection R•pe: �1 _ amount: Q completion of Avell construction to the county health department of the county
where constructed. �
Form G\1'-I North Carolina Department of 2aaironm2wal Qualitv-Divisio.-.of Watcr Resources Reused?'?-2016
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