GW1-2022-10240_Well Construction - GW1_20221111

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Onl .
1.Well Contractor Information:
Russell Taylor t14.WATER ZONES
Well Connector Name M TO D SCMMON
2187-A n 70 11 r7 —17
7D fG1,3r75 ft-1-1I
YC Well Contactor Canifiattion Number is.OUTER CASII\G for muttt—ea wetly ORLINER cable
Hedden Brothers Well Drilling, Inc FROM To 1 DlAdtErt{R Mr1TIM"
ft. ftI j !n.
Company Name //�� ����++ 16.M ER CASING OR TUBINGoo closed-(
S.Well Construction Permit#: O(b-,f99'74- 9- 11290 FROM I To I I DIA,titUM I T111CM-MS MATO AL
Un aU appamble'tuft Mmucdon pernifts C1.0.UlC.Cotarry,state Varranee.etc) R n! 10, Ye
I Well Use(check well use): rrI fl i! in
1"Irristation
ater 1 Well: 17.SCPXM I
`�p y FROM TO 1 DIM1EM SLOTSIZS TffiC1 FM DIATERLIL
Agricultural 13Municipal/Public tt ft.
Geothermal Weating/Cooliag Supply) 1JoResidential Water Supply(single) ft. ft. i fa
IndustrwIlCommereial [1Rcsidential Water Supply(shared)
1&GROUT I i
iFROM TO I MATERIAL 1 EMPLACLN1M Vl OD&A>fOttlT
Non-Water Supply Welk o• zo o.pad
Monitoring Recovery ti tct
ection Well: ft. f
Aquifer Recharge Groundwater Rcmediation
Ct Storage 19.SANDIGRAVFL PACK if a lieable)
Aquifer rage and Recovery Salinity Barrier SROhi TO I a TEMUL Fsfrt.AMtERThtM515
Aquifer Test '2StormwaterDrainage Ift. fz
Eltperimental Technology 0,Subsidence Control Im f
Geothermal(Closed Loop) Tracer 1 20.DRILLING LOG attach additional sheets if a
Geothermal(Heap Cooun Return) rjOther(explain under#21 Remarks) FROM I To I DFSCRIPTIO%[color.hardness.soithaek a stm fuel
0 A• I day S sand
4.Date Well(s)Completed: lOf We1l1D# t"oo f� srd^i-
5a.Well Location:
rri4Vetrs Yiiiwle.. LW
i
Fae(Iity/O"='14attu Facility lDw(ifapplicable) ft. i rt. 1
C shim Fas+ ViIW OgAi es. 28r1 t 07
Physical Addn=..City.and Zip U
ft
NOV I
JpOJ*QS -- 31.REhrARKS
Couary Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fold,one lottloog is sufficiern) 22.Certification: I
M" M. '137 N 0830 05. 89'1 W =/j��-�r, to t�
6.ls(are)the well(s) Permanent or OTemporaty
Signature of Certified Well Contractor �- Date
d)signing thfs fora,l hEl Iee"0.d. 1 iRl1(SI���her r)can.mrcred is axordaau
7.1s this a repair to as esistIng welt: joYes or No wuh 15A NCAC 02C S d0 or If i,VCAC 0W.0100 1*11 Cantthtetlan 9andordt and Mm a
(this it a rrpatr.fdl out Maim rvrll construction information rdesplain the nature ofthr com gfrhfs record has be!provided to the ure/1 owner.
repair under 921 mmar/sseerfon or on the back oftfKrfarm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the bacg of this page to provide additional well site details or well
conmction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled' I SUBMITTAL INSTAUCTIONS
9.Tote[well depth below land surface: boo VL) 24a. For All Wells:1 Submit this form within 30 days of completion of well
For ntulttpie urtfs(fit all depths irdtfferml frramp/r-3Q300'and 3Q/001 construction to the foljowing.
10.Static water level below top of casing: y (ft.) Division of IINVaier Resources,Information Processing Unit,
(ftvatar level fs ahow casing,use"?-'• 1617 hJail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter. (I-) 24b. For Injection�i'eits: in addition to sending the form to the address in 24a
above,also submit clue copy of this form within 30 days of completion of well
12.Well construction method: construction to the foAowia8:
(Le.auger,rotary.cable,direct push.etc.)
Division of Wate Resources,Underground Iglectton Control Program.
FOR WATER SUPPLYaW�EjLLS ONLY: 1636 Mai(Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) '^" 14ethod of test 24c.For Water Su It•&Infection Wells; In addition to sending the form to
the addresses) abet also submit one copy of this form within 30 days of
13b.Disinfection nge: _i"+ Amount: completion of well clonsiruction to the county health department of the county
where const ueted. '
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Font OW-1 North Carolina Depaaatent of Emironm2ra21 Qralky.Divsion of�I'atcr`Rcsou:ccs Retired%n-'A16
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