GW1-2022-10748_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD (GW- -2) For Intl mal Use Only.
1.Well Conrmetor Information: !
r i
Russell Taylor 14.WAMM&0 s i
FROM TO r DESCIUMON
Well Contractor Nome
2187-A ft. DO
NC Well Coam=CcrtifrGttion Number IS.OUTER CASIIVG for mnitt cued wells ORLIIYER iff k
Hedden Brothers Well Drilling, Inc FROM Ta I DrAntErER rxrcrcv> s HATRUAL
fr. fG in.
Company Name '
n n D 16.�I1V'ER CASING OR TUBIlVG e:aNtertaal elweddao
2.Well Construction Permit#: IJ to a—if FROM I TO DtA.NM R I Their M ZATERM
Use all oppilcahle udl ra Mtetlon pe mits(r.c.VIC,County.State.VaHatme,eta) rL I It.
In.
3.Wen Use(check~Yell use): ft. I ft. bL ,
Vial/Commercial
Wells 17.SCREENpplY FRObt TO DtMlEl6R SLOTSIZE THIC[GtiBSs DfATERLIL
tttal �lvituticipal/Pub[ic fa ft.mal(Heating/Cooling Supply) §Residential Water Supply(single) fr. it in.
DResideatial Water Supply(shared) I&GROLT
W FROM TO SfATERLtL I )NrPLaCM1LNTSIErHOD&A-'%10 M1T
Non-Water Supply Well:
fL I zc fL I anx aeon• ormened
Monitoring - Recovery _ fL fL I
Infection Welk fL I fL
AquifcrRcchargc OGroundwatcrRcmediation I9.SANDlGRAVELPACK ifs iresble)
Aquifer Storage and Recovery Salinity Barrier fttaM To �L11ERtaL F3tpWt�M1tS\T]tEIHOD
Aquifer Test J3StortawaterDrainage ft fn 1
B:tperinacumI Technolory OSubsidence Control ft j
Geothermal(Closed Loop) 0-Tracer f 20.DRILLM- GLOG ottscb additional sheets if n
FROM TO 'I DESCRIPTION teelor.Iuedaeo.soalrock a sta.tle)
Geothermal(Hearin Coolid Return) Other(explain under t31 Remarks) 0 'clay&sand
4.Date Well(s)Completed:Af o r,r40.72 Well ID;> I f` I ft I I granite ,`"�
Sa.Well Location: N
—
i►�dr,
,,I rX
Facility/Owaa;'1 Facility lDR(ii appiieable) fr. ft.I J
fn
Pbysicat Address.City.and Zip
fa`�8lvoa�o ray , z1'R�a•1Atucs
fnp&,) iVT�I I u, —3oaP+••
County Parcel Identification No.(PLC)
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if weu 6011 one lavloag is sutlicicat) 22.Certif cation:
ii W I
Signature ofccnificd WelljContractor atuDate
6.Is(are)theae)1(s) PetTnanent orTemparar}
8p slgtriag tlrls f0mr.I her eertij} thataIrrtll(s)real curry)etion and!a aeeardutt a
7.1s this a repair to an writing well: E3Yes or No uttlt ISA VCAC 03C.0100 or IS.-i VC9C 0?C.0200 rF811 Caasmretfan Staadardr arrd that o
/f thrr tr a rrpair,fdt out knoaw 1veil earutruarion irrfarmarlor. ,cbraplairr rF.e rserur..oftlrr _ -PP gfihis recrord ryas been prarzdrd to the url!onaer
rrpair rardrr p?l remarfasecrian or air the back ofrUrfamr. 23.Site diagram or additional well details:
S.For Geo robeJDPT or Closed-Loop Geothermal Wells having the same You May use the back of this page to provide additional well site details or well
P P construction details. You may also artach additional pages if necessary.
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: ( IL SUBMITTAL INSTRUCTIONS
9.Toed well depth below land surface: -(fL) 24a. For All Wells: :Submit This foray%within 30 days of completion of well
For atalttplr hells fisr all deptla lfdderent trsampir-3@300'and 2010111 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lflvatvrlow[isahotrcatlar use . I617MsI&ServiceCenter,Raleigh.;•IC27699-7627
11.Borehole diameter- ga.) 24b.For Infection Wells-: In addition to sending the form to she address In 14e
above.also submit one copy of this form Nrirbin 30 days of completion of well
12.Well constructioti method: construction to the fol vciae:
C-t-anger,rotary'.cable,direct push.etc.)
Division of 41'ater,Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
I ;
13a.Yield( m) 1Iethod of test: ` 24c.For Water Sunoh'&Iniection Wells: In addition to sending the Perm t
the address(es) abevi; also submit one copy of this form witbin 30 days o
compicrion of.yell el nstmction to the county health department of the eoturt
13b.Disinfection type; Amount: tvnere constructed.
Form G1�'-i North Carolina Depanmcnt of Sarl:ansren::1 Q�iit;•-Div'siva o:R'atcr Resou:c�
Rctssed 2-'=-101