GW1-2022-08912_Well Construction - GW1_20220912

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WELL CONSTRUCTION RECORD (CW 1) For Internal Use Only.
1.Well Contractor Information:
Russell Taylor 14.WATER ZONES
%veil Contractor Name FROM TO IDESMPTION
2187-A r`• 174 �
77
NC Well Contractor Cattification Number 15.OUTM CASIIQG for muttt.eased webs OR LINER(1f a cable
Hedden Brothers Well Drilling, Inc PROM To DIAMETER K
ft. ft. in,
Company Name
A��1 �1 ] t 16.V1NER CASING OR TUBING(Reath dosedlanal
A
2.Well Construction Permit#: 1-4�818—9-113f'oJ!' FROM I TO DiaNtZ= I THMC1evm I MATMAL
Litt all applicable nett evntmtellon permits(.a UIC.Cotuto,State,Variance,etc.) �• �0 it. ' In.
3.Well Use(check-weI1 use): 70 ft. I 1 a tL m e
Water Supply Weil: 17.SCREEN
FROM TO DIAMETER SLOTSiZE THICKNESS 51ATEPJAL
Agricultural 13Mtnricipal/Public ft. fr. im
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commarcial Residential Water Supply(shared) ill GROUT t
Irrigation FROM TO 4tATEMAt Er IPLACLNILNTh(ETHOO&A.\IOL'NT
Non-Water Supply Weil: 0 M 20 rl asmaaerru aumvad
Mortitoring 13Rccovery m ft.
Ajection Well:
Aquifer Recharge 00roundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 12-Saliniry Barrier FROM To '.rATERLLL I EMPLACEMENT METHOD
Aquifer Tea MStormwaterDrainage ft. fr.
Experimental Technology Subsidence Control fr. ft
cce
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attacb'addttlonal sheets if ass
Geothermal(Heatin Coolin Retum) Other(ex lain under 21 Remarks FROM TO DESCRIPTION(color.hardness,saWmtk G 1ns�ttel
ft. fL ':,ciaY S sand
4.Date Well(s)Completed: o?oa2 W'ell IM ft. granite
So.Well Location: ft. ft.
O'
Facility/Owner Name — Facility IDd(if applicable) ft. ft. I v; � ',�j C U
Pa#5 (..cinMmw,i-1� J2d. Altom.. e?87rj9 is rt.
Physical Address,City.and Zip T— ft. i ft. I _ t_
1,�A('ILSON 1.om �I r7WO 38- 8+ 1 { Off 21.RElfARKS ro-
r'
County Porccl Mdcntihcarion tio.(Pink r n
5b.Latitude and longitude in degreesimlautes/seconds or decimal degrees:
(ifweli field,one ladlong is sufficient) 22.Certification:
350 40. 17107 N 0 830 14 765 W 8 8 aca2
6.1s(are)the weil(s) Permanent or QiTempomry Sigtaturcof Certified Weil Contra ctor Dew
T111 By signing this form.1 herrbr certify that r nrll(s)Bras(urre)canrtrueted in accordance
7.Is this a repair to an existing wail: nYes or No nith 15.4 NCAC OZC.(100 err JS.4 NC9C 0ZC,0200 Well Construction Standards and tha/a
If this it a repair,jV1 out knonu tvril construction information taesplatn the nuntre.of the cops of this record has been prarlded lathe aril 01t7ler.
repair under i:21 remarl¢seation or on the back ofthisfarm. 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 I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: T SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: j`s y (ft-) 24a. For A7I MLIells: Submit this form within 30 days of completion of well
For multiple terl&i&t all depths if different(ammple-3@200'annd 2@1009 construction to the following./
10.Static water level below top of casing: et00 (fr.) Division of Ni'ate.r Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail S4vice Center,Raleigh,NC 27699-1617
11.Borehole diameter:` (in.) 24b.For Iniection Werllso.'in addition to sending the form to the address in 24a
n above,also submit one copy of this form within 30 days of completion of well
12.Well constructiod method:_il � �� construction to the following:
0-aug-,mfaty,cable,direct posh,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) Ion DIethod of test: 24c.For t4ater Suooly&Iniection Wells: In addition to sending the form to
rr�� the For
above, also submit one copy of this form within 30 days of
13b.Disinfection type: r` amount: L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of En-ironrncntal Qtalitl•-Di isio.:of):rater i[csoumcs Rcvised 2-1 -2016
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