GW1-2022-09501_Well Construction - GW1_20221014

PrIFlt Fom
LL CONSTR CTION RECORD (CW-I) Foe Iniemal Use 0'ly: ' --
1.Well Contractor Info tion;
Russell Taylor 14.WATER ZONES i t
Wall Contractor Name FROM TO I I DESCRIPTION
21 g,-A AA s F a Ia7 a3
NC Well Contractor Ccrffia oaNumber Or�t55ft• Q(60 I I !
W.0V=CASING or mold-cased welLv OB LIIYEIt fif Te
Hedden Brother Well Drilling, Inc FROM To Mt DIAETER rtrrcrora:ss NATEWL
Company Name fr. In,
,,
26.INNER CASING OR TUBING ertaal dosed-loo
2.Well Cotimcdon Pe •t#: -0609:w-P FR031 TO I DLL,+tETFA THT ESS MATERIAL.
list ail appllttrblr ntt11 cams on permits Cl.a.07C,Conary,State.1'adartce,etc.) 0 is. I J.',5 I. � In,
pyt,
S.Well Use(check well I me); fr. I41 ri tt- m. a l A A LW �� e
[3A
Supply Weil: 17.scREN
FROMt TO DIAAIMIt SLOTSIZE THICKNESScultural rJMunicipaYNblic ft.hermal(Heating/CDoling Supply) EbResidential Water Supply(single) ft. fr.strial/Commereial Residential Water Supply(shared) 18 GROUT
ti0nFROM TO -MATERIAL EMtPLACQUOrrAMMOD •A.1IOI51T
ater Supply Wel: - - - 20 �ae�a aid -- ---
itn W I MRecovery it.on� ett: fLfer Recharge DGroundwatcr RcmediationftrSto 19.SA IGRAVELPACK Ka Geable)rage aid Recovery �SaliairyBarrier FROM: TO l tiIATERLIL LXPLACEMESTM 71101)
fer Test [3stortnwaterDminagetimentalTechnology- OSubsidenee Controlhermal(Closed LoDp) DTracer 20.DRILLk\GLOG attacbadditionalsheets ifnhennal Hearin Colin Return) Other(explain trader 21 RemarY,$) FROM r0 I OFSCHIPTtO\teofor.turdoea satUrnek a n miss etzl
It. I It- 'clay 8 sand
4.Date Well(s)Comple d: oa? !fell ID# fr. 300�` I 'granite
Sa..Well Location: ft. (t.
fr. #t.
Factl{ry/ Natac Facility EDmtifappliaabla)
Physical Add ,C{t.and p _r fr• f -
E
m,,�,,,•--,/1 l 31.ItEhZ4ItKS •-_
L L4Sd1�l�pl7 {Ctit3i:a :a:r;
County Parcel Identification No.(Pitt r tc l
i
5b.Latitude and longia Lde In degre"Imiautes/seconds or decimal degrees: i
(if well field,one lavlong issufficient) 22.Certification:
50 06.43 5 N 0&3° o?oa.440 W I i
5ionatutc ofCcrtified We 1 Contiactor Dad
ts 6.Is(are)theell($) ermaneut or OTempor•arp , ,
ay s%niag this form,I hill - 1.certify-that i itril(s)tws(litre)caturmcfed in aeeardaner
7.IS this a repair to an eststing well: E3Yes or No xirh ISA NCAC 03C.01d0 or.---------03C.0300 JFe1l Construrdkm R=dardr and dial a
#'Itt is a repair,fdl out knc an ivrll construction information aesplaia the nature,of the ropy°!this reeard It=be pmiided to the utl7 owner.
repair andtr r;31 rrrtranEt section or on the back ofrhLrfomr.
23-Site diagram or a d1donal well details:
S.For Geoprobe/DPT i Closed-Loop Geothermal Wells having the same You may use the bw, of this page to provide additional well site details or well
construction,only I OW. nsau
I is needed. Indicate TOTAL NUMBER ofw•ells cocdon details. �ou may also attach additional pages if necessary.
drilled: SUBMITT t STRUCTIONS
9.Total watt depth belo land surface: A) 24a. For A I Rrelis: Submit this form within 30 days of completion of well
For multiple,ttoft I&t all de lies)fdWer-i ie-cmurple-3Q200'and 2@1009 construction to the fol{1 sib
10.5tatie water Ievei b �low top of casing: 0 (fr.) Dlrision of"4ater Resource$,Information Processing Unit,
Ifivarer/owl it above Cork,t,use'=" I617;NT JI Service Center,Raleigh,NC 27699-M7
11.Borehole diameter. (re,-) 24b. For Infection e{lsp In addition addition to sending the form to the address in 24a
above,also submit or,a copy of this form within 30 days of completion of welt
12.Well construction erhod: 1 )t. d (y � construction to the following: ;
C!a auger,rotary,cable.data ptssh,etc.) I
I.
Division of�lk'ateriResources,Underground Injection Control Program,
FOR WATER SUPPL WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
,
13a.Yield(gpm) Alethod of test: 34c.For Water Sumfl 8�'Iniecrion__Wells: In addition to sending the form to
LV it the addresses) abov also submit one copy of this form within 30 days of
13b.Disinfection type: /iA Amount: completion of well c nstr crton to the county health department of the comity
where constructed.
Form GW-1 North Carolina Deparunant of Enviranmant:l Qca:ty-DiYsior.or-W ater T l �urcgs Rinsed 2-221-2016
I �.�