GW1-2022-08901_Well Construction - GW1_20220912

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WELL CONSTRUCTION RECORD (GW-1) 71;;ce Mal Use Only
1.Well Contractor Information: 7
Russell Taylor 14.WATERZOiiTES f
FROM TO DFSCIUMON
Wail ConnactarN�e oft. � !
21 s7-A &o 5 it. - 195
NC well Contractor c4r ificstiaa Number 16.OUM CASING or multi-eisea-elh ag1, (K able
Hedden Brothers Well Drilling, Inc FROM To otAbti:rER Tllt NA
ft. ft. in.
Company Name
D 16.4�IIQER CASINGORTUSING ermal eloseddoo
2.Well Construction Permit#: 0415aa- ! FROM TO OLIMETER CXNW I h1A
UV all applrrohle irdl construction permits(t.a UIC.Cotorry.State Variance,etc.) n• i T 1L ln.
3.Wen Use(check well use): t' ft. I 1 sa 3n 8 r
[1-d.strial/Cmumarcial
supply Well: 17.SCREEN
FROM TO DWILTI R SLOTSIZE THIC[C\ESS MATEMAL
cultural (3Muaic(pa.Mblic ft. ft. in
hermal(Heating/Coolins Supply) Residential Water Supply(single) {t. ft. l im
E3Resideatial Water Supply(shared) 18.GROUT
FROM TO �I TERLIL EAIPLA tl1-r d[ OWater Supply Well: ft 20 tL as+en6ee�rse aumved
itoring ORrcovery tt tt.
I
ec onW ell:quifer Recharge �Grottndwater Rcmediation ft.quifer Storage and Recovery [3salinity Barrier FROM l I TO P CK N �Ie UMPLACEMR� MVITIOD
quiforTest 0StormwaterDrainago ft. toxperimental Technology Subsidence Controleothennai(ClosedLoop) 0Tracer 20.DRILI.LNGLOG attach additional sheetsltn
eothermal(Heatin Coolie Return) Other(explain under#21 Remarks) PRont TO rtiEst'Rrrnts\reeler.ha,daen saNteck e n rtrs etnl
CI,. I ft- !c
J lay S sand
4.Date Well(s)Completed: Well 1D# n rL i9�fte
Sa.Well Location: �• n '
I�t s1 Ca ` fr. ft.
Faeilfty/OwnaNamc Facility ID (ifapplicable)
Rays Cabe Rd• Ott , o?87IP3 CL
Physical Address.City,and Zip ft. ft.leHP 1
9 2022
A*0014 l 0�111�T Y W Ty$go( � 21.REh1ARXS
County Parent Identificarion No.(PIN)
✓�'dll7,r Gam::
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(if wcu field,one ladlong is sufficient) 22.Certification:
34 0 51 r1B4 N 1) 0?°-1;z
6.Is(are)the well(s) permanent or Temporary
Signature ofCcrdficd%Veil Connector Data
8j sigaing this form.1 hereln,eeritjy that i i,rA(s/,tact Gir t)cat nucted In accordance
7.is this a repair to as existing well: rlYes or No is-all ISA NCAC 02C.0l00 or ISA.VCAC 02C.0100!Yell Consaverfon S7andards and than a
#'AW is a ropoir,fdl our knomi ivell construction injarmailon tsplain the ratan.of the ropy grthis record has been promided ro the well owner.
repair under#21 rrmarlosection or on the bark ofrltlsfarm. 23•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 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
drilled: I L rj s, SUBMITTA INSTRUCTIONS
9.Total well depth below land surface. den l J (ft-) 242. For.411 Wells: Submit this form within 30 days of completion of well
For multiple urlls list atl deplAr tjdarrent(examph-3@200'arrd 2@1001 consLmction to the following:
10.Static water level below top of casing: 3f� (ft•) Division of Wafer Resources,Information Processing Unit,
((Iswrrlevel is ahoiv casing.use I617 Mail Service Center,Raleigh,NC 17699-1617
11.Borehole diameter. (tn.) 24b.For Infection-Wells c In addition to sending the corm to the address In 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Cnh --5-- construction to the following:
Cis ect aaser,rotary,cable,dir push.etc.)
Division of Water Resources,Underground I>dectioa Control Program,
FOR WATER SUPPLY!YELLS ONLY: 1636 Mall Service Center,Raleigh.NC 27699-2636
13a.Yield(gpm) v D 13ethod of test: 24c•For Water Sunoiv`&Iniecdoa We►la. In addition to sending the form to
i the addresses) 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 OW-1 North Carolina Department of Ensironmenul QLal(ry-Division of tt'atar Rcscurc's Raised2-?�-1016
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