GW1-2022-08911_Well Construction - GW1_20220912

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WELL CONSTRUCTION RECORD (OW-I) For Intemai Use Only:
i.Well Contractor Information:
Russell Taylor 14.WAIMgM
FROM TO DESCRIPTION
Well CoasaetorNamc 5� 1440
a I.�fy 02 O� 15
2187-A
- 80 ft. flr.
NC Well Contractor Certiiiention Number 1 15.OUTER CASING for math-cued webs OBT' 'W"
W eabie
Hedden Brothers Well Drilling, Inc oht To nrAht>:TER THICKNESS MA
Company Name -
I6.LVNERCASINGORTIIBIN ertaalclosed-lop
+ iROM TO DIAM-E(2TER THfCi -- 11ATtiR1AL
E.Well Coustivction Permit#: �laoZ��a3O��—� ���%!.�
Litt all applicable mW mumtedon pttrtnirs fl.e.WC,Catatty,Stare.Variance.etc.) I. n• J40 R. In. - 188 t5 TESL
3.Well Use(check well use): it in
L
Stirppiy Well: FxohC To DrnnrETER SLOTSiZE Tx1ct�Fas MATERL+L
cultural 0municipal/publichermal(HeatingJCooiing Supply) ResidentialWater Supply(single)t�ial/Commereial Residential Water Supply(shared) 15.GROUT
Initiation FROM TO iMATERJAL I Ll LNrN[LrHOD&;LtOLT
Non-Water Supply Well: 0 ft 20 D' eenratvrse pumped
iNoaito:tirrg Recovery R. R.
njectton eT1: I ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage 19.SAMIGRAVEL PAC[C 1f a licable)
Aq rage and Recovery MISaliniry Barrier sxohl To JLITEMAL paSPLAC1TtEtTbtIiTHOD
Aquifer Test [3StottnwaterDrainage ft. fc
Experimental Technology Subsidence Control ft. 1
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if neces
Geothermal(Hew oolin Rerttm) Other(explain under#21 Remarks) rTtoat To oeseRtPTtox teom rurdoea saturoek n v�ae stW
/^, ft. I U R clay a sand
4.Date Well(s)Completed: a Well ID# j 0 f`' I f` Basi1e
Well Location:
ft, ft. �J
Fac[ltty vxTtame Facility Mr;(ifappGeehie) l ft. ft.
physical Add ity.and Zip i L4 : _
'�_63-4'�4 q A.I.REbAItFCS
I
county Patccl idcntificadon Na(PLC) Unit
5b.Latitude and longitude in degreesiminutesisecoads or decimal degrees:
(ifwall Geld,one lavloag is suf6cicat) 22-certification:
35 AM 177 n 0830 ►4. 330 W g /o koaq
6.Is(are)the wellm permanent or Temporary S[ma[urcofCerdfiedtVellCdnttaetor Oates
By signing this jorot•1 hereby cer46-that urll fs)aras(were)coattruued in atawrdancr
1.Is this a repair to an existing well: CJ Yes or No uirlt ISd NCAC 03C-0100 or IS.t,YCAC 03,0700 Iieff Construction Sandands and that a
j14lr tr a rrpoir,fdl oat known rrrR construction info MaI[aa Zrzplain the nature.of the copy of this record has been provided to the mil ouster.
rrpoh-rmdir 1021 remade section or on the baadr afrAls farm. 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTI0IS
i
9.Total wail depot below land surface: 3DO ft*) 24a. For A)l Wells: Submit this form within 30 days of completion of anal
For multiple uw&arr all depths irddenmt(esamp/r.3@200'and 2@100') construction to the following:
10.Static seater level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ijtvatrr/earl&above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Cfn) 24b.For Infection Werra: In addition to sending the form to the address in 24a
(� J above,also submit one copy of this fort within 30 days of completion of well
12.Well constmetiori method: L 11,1 /lL} �t�1 construction to the following:
C—auger,rotary,eabl0.dimt push.eta) V
Division of tv'ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY YELLS ONLY: (� 1636 Alai)Sarvice Center,Raleigb.'IC 2 76 99-1 63 6
13a.Yield(gpaa) ion "Iethod of test: i j tOUD 24c.Far W ter Suo3311'Z.Infection Wells; 1n addition to sending the forth to
the addresses) above, also submit one copy of this form udthin 30 days of
I3b.DisinfeciloD rapt. Amount t completion of.cell contitruetion to the county health department of the county
where consnueted. I
Form Ott`-1 North Carolina Deparrrr gym[of Eivironm:vnal Q:nlhv-Division.of-accr Rcsou:c s Revised 2-?2"-1016