GW1-2022-10806_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD(OW I) For Intemal Use Only'.
1.Wall Contractor Information: !
Russell Taylor 1 14.WATERZONES I
FROM I TO I 1-1 DESCIUMON
Well ContrdcmNamc JAJ0fa JAJ -J
2'187-A
I ,.f fr. fG gJr' �'400
NCWcl(CoetrsctorCtxffi=doaNumber I I5.ODTERCA3Mrx farntmlde�sedwells 08LIIVER(1! es3ic
Redden Brothers Well Drilling, fnc °`t Ta Dl'u`t 'xlet�s
r4 fG m.
CompanyNtone ' 16.TaY1 MCASING- TUBING(geatti-scudcioseddae
2.Well Coastmcdou Permit Olt dggl-&r7Or?-9 0,9'74 TO ! DWILTM I TlnQQNLss Is1�r8sut.
bran all opplltable aril eowuctmn permfu Cu.Mc.County,Stares Varfer ce,etc) I. � R• I �; C
3.Well Use(Check ira use); ro. b '
17 SCREE; i
Water Supply Wells FROM TO 11 Die ILMR I SLOT S1Z5 Tlat'E1i'F35 1IATERiaL
Agricultural ft, I ft. 4n.
Geothermal(Heaal orCocling Supply) WResidential Water.Supply(single) ft, It I ia.
IadusaiaVComtaercial [3Resideatial Water Supply(shared) IS.GROUr ' y
hri flan FROM I TO i I3tATt:RLIt i;,rrtacsas�-ratErxoD�A�sotn
rAquifbrR=hargc
erSupplyWeib 0' z°: n' a �. pumped
DRecovery, IL
♦ ell: fr.] ft.
argc E2Gmundwatcr-Rcmediation 9SANINGRAVEL ACK ff it—,l13
Storage and Recovery MISaihtnyBarrie FROM To , NfATERLIL E}tpuela►s \TDIE HOD
Test MStormwatarDramaga ' P-
ental Teclmology Subsidence ControltaaT(Closed Loop) Traer Z0.gR)LLi�iGLCG attach addittoaalshFROM TO C I DESCRIPTION teolor.hardaea.saQhaek siu.d0
mal(Iieaddn Coolin Return) other(explain under 21 Remarks) fr. I �� IfL!I y a sand
4.Date Well(s)Completed: r+l�+t Wel1,IDT
Sa.Well Location: fr. ft. ' sue. &—° "m['•'
&M4
Faciiity/Owmcllasx Fau'Iity Me(infaPplieable) I It. I I,ft.,
IlnD6 Rc►,Y i�s Ct�e�� wVI+�ey d8'zf
Physical Address.City.and Zip
21.RfiSFAI2FC5 i
Jac Cooart rZW I-14-001la I i
County Parcel IdeadBcarien\o.(PLN 1 '
l
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(if wall gold,ago istliong is sufficient) 22.Certification
a�.Iuo •I 00" 18 491 !i
S(pnaturc ofccrdfibd Wcll;ccmtramr Date
6.Ward)the well(s) Permanent or MTempor ary ' I, • 4
BY signing+his fori,a 1 fterebv certify that %Mftj.cos(nerr)caasaueted fn aeearda,
7.is this a repair to an existing well: MYes or \o aftlt 15d NCAC 03C.0100 or ISS:CAC 03C.0200 n'rlt Cansrryrtfon Srandwdr tied pre
If thin is a rrpafr.fdl eat Anoaa WITH eonstrrrUton lofarn,atlon a4eo�rsplain the manor of thr ropy ofthfs rteard: been praL�ded ro the rrelf oxxes
_ nepafrundrrinZlrrmmts:r�ronaroe-the-eackofdrtsfarm__- __ - 23.Site-diagralrior3dditional well details:
You may use the back of this page to provide additional well site details or a
S.For Geoprobe/M or Closed-Loop Geothermal Wells having the same construction details.I You may also attach additional pages if neetsM-
constmcdon,only 1 GW-i is needed. Indicate TOTAL NUMBER orwails
drilled: 17 supmITTAL inim ICTIONS
9.Total well depth below land surface: "7e:M (i t-) 24a. For All �tiT_: Submit this form within 30 days of completion of%A
For multlplr nbl&fin aft depths ffdiprrmt tisem1lr-3@200 and 2@100.1 construction to the following:
10.Static water Ievet below top of casing: C (fr.) Division of Maw Resources,Information Processing Unit;
fftiwter fen rl it nbovr casfns use'=)" 1617 Mail Service Center,RaWob,%IC 17699-1617
11.Borehole diameter: l O (Fn-) 24b.Fnr Iniecr�ton 1Ve11s: In addition to sending the form m the eddtcss in:
above,also submit brie copy of this form nithin 39 days of eompledon of c
12.Well eoastrnetlori method: Lit er -- construction to the jail;gins•:
(Le_auger,rotary,able,drtcot push,ct=)
Division of}vater,Resources,Underground Injection Control Program.
FOR WATER SUPPLY NVELLS ONLY: 16361Mall Service Center,Raleigh.VC 27699-1636
IK
13n.Yield(gpm) A3etbad of test: 24a Far��`ater Snntiiv&Iniectiast Wells: In addition to sending the fort
the addresses}above, also submit one copy of this foan mitbin 30 daya
13t1.DTsiafection t}pt._ _ completion o-kvelI eonsttuction to the county health department of due cm
Amount'.
where eanstrueieti! '
�• Rstiscd 2,11-:
Form OW-1 Norch Carolina Deparvment oM:%iraarr=,2J Q:-!: -tJil�oa o tt'star Rcsou c�