GW1-2022-10232_Well Construction - GW1_20221111

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i WILL CONSTRUCTION RECORD (OW-1) For Intemal Use bnI}r
1.Well Contractor Information:
Russell Taylor 1 14.WATER ZONES
FRO2.S TO .1 DESCRIPYION
Well Contractor Name rl} tc. ft.{
2187-A
NC Well Contractor Cettifieafiga Number 15.OUTER CASING for'maltl-cued wells 08L1IRFR(if tattle
Hedden Brothers Well Drilling, Inc moat 'TOnIAnIErER rli,ttc�ss INATBRIAL
I- R. fL1 � im
Company Name 1 16.2MR CASING OR ING aathermal clostedl00
2.Wen eoastructiion Permit#: 1)4 6 1 .1 P _ FROM I TO I DIAXEFER MnCIG'M b1AT6R1AL
List all applicable aril rooter don permits Ci.a WC,County,$tare.Variance,eta) o R• In. YG
3.Wen Use(check wen use): .1-3 tr. I tt.? hL TEE17.SCREEN
L
[Innization
Supply Welk• FROM o nuwtETSR st.orslzs THICKNEEss OATERUL
cuitural �MtuticipalfPubGc rt t.hermal(Heating/Cooling Supply) Residential Water Supply(single) h. R, to.
strial(Commereiel E)Rcsidenttal Water Supply(shared) IL GROUT FROAf TO MATERIAL WIPLAC&SICW METHOD
Non-Water Supply Well: O 20 pumped
Monitotin E3Recovery tL [t
fAquiftr
l hargc rlGroundwatcrRcmediation 19.SAND/GRAVEL ACTC ifs Heableiage and Recovery �SatinityBatTier FRovt ro a Aeeaf�\T otrrlt Dt 13StormwaterDrainageftai TechnologySubsidence Control u(ClosedLoop) 0-Tracer ZO.DRILI.L\GLOG adsahaddttionnlsheetsifnFR01i TODN teo si7z ate 1
(Heating/Cooling Return) M Other(e:t lain under#21 Remarks) F0 fc. 1 iL nay a sand
4.Date Well(s)Completed. Olt Well IDO granite
ft.
(I ft.
Sa.Well Location:
ft. ft. i
Fae t /Owner N to ee Facility MO(if applicable) j ft. {t•
18 m;�h Rid I ►���^t a 8 234
Physical Address.City.and Zip
:1.RE&L4RICR
Maw
't�twaT11 [�55Cd991759 � i
CountyPamcl Identification No.(FIN)
5b.Latitude and longitude in degrees/miuutes/seconds or decimal degrees!
(ifwoll acid,one Iallong is sufficient) 22.Ce 'frcation: j
° 13.9 N p83° 9.S)0 W p 176QS�
Slit".ofCardfied Well ontractor Date
6.Is(are)the tvell(s} TD Petanent or T emporar} ch ,�/.. ,cos term)coArtruued in a=rdmtee
ay signing this fam'.1 h�rcbr'eeAiJy ara
7.Is this a repair to an 6XlSting Weil: [3Yes orpa-expla
llo iddh ISd NCAC 02C.0100 or IS4,VCAC 02C.0200!Yell Consaurttop S7andards and 11'x a
trihis Er a rrpatr.fill out knoarr ivrll construction injarntmionin,he naturo of the copy of ibis record has brier prodded to the trill acme,
rrpo/r undor 921 rommiaa section or on the back oJtltrsfann. 23.Site diagram or Additional well details:
S.For Geo robc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page rt ch additional
additional well site details or well
p P construction derails. °u may also aaaclt additional pages if necessary.
construction,only GW-I is needed. Indicate TOTAL Ntt MBER of wells
drilled: SUBMITTAL INSTRUCTTO�'S
9.Tatar well depth below land surface: TlWM (fL) 24a. For Alt Wells: Submit this fora!within 30 days of completion of well
For multiple a-rus list all depths 1Jdiffwmt(ssamltle-3@200'aan f
nd2 /00') construction to the fo�lowing.
10.Static!water level below top of casing: D� (ft-) Division oill Nttacer Resources,Information Processing Unit,
1JivaterJew1 is shove costar use'•+'• 1617 Al ail Service Center,Raleigh,NC 17699-1617
11.Borehole diameter. 24b. W. 1n addition to sending the form to the address in 24a
# � above,also submit dne copy of this form sithin 30 days of completion of well
12.Well eonstructiori metbod: �� f t - - constmction to the following:
Ct.r_auger,rotary,cable.direct push,eta) u I
Division of Water Re sources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
I3a.Yield( m) Method of test 14C.For Water Suooly 8s InieMian Wells: In addition to sending the ftrrm to
gP !! the address(es) abode also submit one copy of this form within 30 days of
13b.Disil feCtlon type; Amount. t completion of well�constrttction to the county health department of the county
n Witte constructed. i
Form OM'-1 Montt Carolina De�anaant ofEavi:anmen z!Q.iiq-Di r.o t�`•'e r Resoccu:ccs
Revised 2.21-2016
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