GW1-2022-10775_Well Construction - GW1_20221208

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WELL CONSTRUCTION RECORD fGW Il For Inremal Use Only':
1.Well Contractor Information:
Russell Taylor 1 14.WATEBZONES I
FROM I TO DESCRSPTSON
Well Contractor Nam: i 5 ft' 1100 fL ' - rl 0
2187-A c ft. 345 ft. o
NC Well Contractor Certification Number IS.O1l M CASING for multi-eased wells ORLUim of etltle
Hedden Brothers Well Drilling, Inc FROMt To DIAMtECER T11100 FSS tK,tttRIAL
ft. fG fit.
Company Name A l t 16.P�lNER CASPG OR TIISING cotltermal closed-iao =
2.Well Construction Permit#: 050M1 FROM I TO DS%mErER I THTClCMS MATERIAL
Girt aft pppilcdblr tu:11 ronstruCXOn permits(-e UIC,County,SU14 Variance,Vc.) I. 0 R- 190 it
3.Well Use(checkivell use): ID fr. ' 19SfL m' .�Tji- 7'96 '
Water Stt Well: 17.SCREEN
Pply FRONT ITO I DtANEIER SLOTSIZE I MC[t\ESS MtATERUL
Agricultural E3Mun1c1pa)/PubHc It. ft. �•
Geothermal(Heating/Cooling Supply) ffiResiderstial Water Supply(single) ft tt Sa
Industrial/Commercial DResidential Water Supply(shared) I&GROUP
Inization FROM TO StATERIAL I &%IPL4MIEITMIErHODdA-MOLIT
Non-Water Supply Well, It. I 20 ft• os, aevrs. pampad
Monitoring very fL ft.
IC(icothermal
ection Well: it. I ft.
quiferRechargc [iCimundwatcrRcmediation I9.SAND/GRAVEL PACK ifa rieable)
quifer Storage and RecoverySaifniry Barrier rTtoat To �faTt xIA1 E�tpueEMSE�TatEnlon
quifer Test [2StormwarerDrainage
atpetimental Technology Subsidence Control
eothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if n
FRONT TO DESCR{PtTO\Ieolor.Ivriees.satfireek e. :ta etW
(Heatin Coolin Return) Other(ex lain under'21 Remarks) fr. l 8 W1. clay S sand
4.Date Well(F)Completed;1.1 14 Fell IDi' i ft- I Q tt 19�!ite
Sa.Well Location:
I fc ft'
EO,4h Inye5�win+UP- !
Facility/OvmcrVamc Facility ID�(if applicable) i ft I
Physical Ad ity-and Zip i_^ `,J p
��to05 H�180
mAMt,c��� I
County Parcel Identification No.(PLC)
i
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iadlong is sufficient) 22.Certification:
t350 0. 484 -91 1,53 « II oZt a�oa.2
6.Is(are)the well{s} Pettnaneat orTemparary
Sigstatum of Certified lVcll'Contractor
Datc
0T+ By signing this Jorn:,1 hareb,:•certify that t scrll(s1 teas(wear)eanctrueted in aaea+'daau
7.1s this a repair to an etisting well: [3Yes or \o »frlr 15.1 NCAC 02C.0100 or IS..I VCAC 02C.0109 Mell ConrtruCrion Standards and that a
Ijrhir it a repair,Jdl out hrtmvtt,vrl1 rotutrauion iaformatioa. .C.'.1ain the rotor..ofthe copy of this record har beea provided to the+tell almer.
ropair•andir 921 Pen='1=Jrrl1on or on the bacl•ofthisform. 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
consttuctien,only 1 GW-I is needed. Indicate TOTAL N'i MBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
4.Total well depth below land surface: (ft) 24a. For All Wels: Submit this form within 30 days of completion of well
For mahfplr n r11r list all deptlts ifddrred(rramplr-3Q200'and 2@100') constriction to the following.
10.Static water Ievel below top of casing: (fr-) Division of�Vater Resources,Information Processing Unit,
Iftvatrr level iv ahoy casing.use" 1617 Mlsil Service Center,Raleigh,NNC 27699-1617
11.Borehole diameter. (ln) 24b.For iniection Nyletls:. In addition to sending the form to the addtsss in 24i
above,also submit orie copy of this form within 30 daya of completion of wet
12.Well constructioti method:_ _h 1 CL�(1�' '�`� construction to the follo-wiae_:
Cu-auger,rotary,erblc,direct push,etc.) j
Division of vwateriResources,Underground Injection Control ProEram,
FOR WATER SUPPLY WELLS OINLY: 1636 Dhail Sen ice Center,Raleigh,NC 27699-2636
13a.Yield(gpm) W llethod of test 24c.For W ter Suo+iv&Iniection Wells: 1n addition to sending the form t
the addresses) above, also submit one copy of this form mitbin 30 days c
I3b.Disinfection type: i i"! Amount completion of well construction to the county health department of the court
where constructed.
Form GNV-) Relined._ 01
'Noitlt Carolina Depastrr:ent of 4n+ron:ren:xi Q:.^.liw-Divsio.-.o:\:xtcr Resou:c�