GW1-2023-00787_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD (OW 1) For Intemal[T$e Only:
1.Well Contractor Information:
Russell Taylor 1a.WAMZONES
WC11 contractorNene Mold, TO I I DEREMP11Or
nn 2
NC Well Cotdnctor Certification Number I 2112� ft1 '
JAN 1 s5.10UTERCAsaNG ormalttc►sedwelb ORz1NERnf cote)
Hedden Brothers Well Drilling, Ind. r FROM m ntAatsrElx Trnctenss MAJURIAL
Company Name In;c.;r.t �,,: �Oiy
I6.1biNER CASING OR T[JSING tSmul elmat-loa
I.Well CoutructioD Permit#: I I rl FROM Ta ' DtA..NMTM I TMIMMS I MATMAL
Un dll oppficobfe Nutt eommWon pernuts Cl.r.U!C•Cotmry.State;Va iawe,eta) I. 0 lt. I ft ln.
S.Weil Use(check Ira use):
lowthermal
StipplyWell: 17.SCREEN iFROM TO i I Dt TE= SLOTSrze THIC[4YFSS MATERIAL
13MunicipaUFublic ft.hermal(Henting/Coolias Supply) OResidandal Water Supply(single) ft 6. ' isOResideatial Water Supply(shared) I&GROUTFROM TO NATERLtL EMPLACE41MMMETHODdW1015,,57
Water Sapp$'Welk tt zeirL . oampaditoring Recovery R fL
'fr. ft
ifcrRcchargc 0GmundwatcrRcmcdfatfonifer Storage aad Reco 19.SANDIGRAVEL PACK if a licablel
very M-Salwi:yBanrier FROM TO1 MAMUL F-MPLACEUfE\T� OD
iferTest 0StofnnwaterDrainage ft. f nTechnology Subsidence Controlhermal(ClondLoop) D-Trdcer 20.DRILLLhGLOG attaebadditionalsbeetsff(Hearin oolin Retum) : Other(ex lain under#.21 Remadts) FRONT To i DESCItrPTf4\lcoror.turdneo saNreek sSa ere t
T� fa 1 ft- emy&sand
d.Date NVelf(s)Completed: 0 Well ID {A
So.Well Location: l IL
Mar are,t V�/
/, I fr., ` it
, K.renu, i
F&cd'ey1 c.laac Facility ID�-(ifapplicahle)
Et-
Physical Addrem City.and tip fa ' ft
• /Y1A[SetJ CounlT! �1�4-ta.3�83 dq , n.RE;}faRtts � I
DR.ui�lc� w �>�.e o 1,� t+E►.—800c+•>
Calmly Parcel ldcntifreatfan No.(PLC) ,
5b.Latitude and longitude in degrees/rolnutes/seconds or decimal degrees: 1
[if Wall field,one latillong is sufficient) M CertMeations;
6.Is(are)the wen(s)ix
Permanent or OTemporary Sig=urcofCerdficdNwiCantrmr o
sy signing ties form.I her, certify riem r ararsi Iras(were)eaarrmcred(a accardw
7..Is this a repair to an esisting well: [3Yes or No_ ,+itlr ISd NCr C 02C.0I00 or 15.3 NCRC 02C.0200 Jii11 Gortstructian Strndardr mud tJm
ltbir fs a repair,jdlau!@noun tvr/!eonstruulon tnjornration rr?esplair.the nature.ajdre ropy orthis record liar been prav!ded to the trell oavter.
mpalrmtdrr#21 remarla•seulan or an the bacP ofth(rJarm. 13.Site diagram'or additional well details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use thel back of this page to provide additional well she details or a
construction,only I OW-I is needed. Indicate TOTAL A''MMER ofseIls construction details. You may also attach additional pages if necessary.
drilled: SUBzM1TTALIIV P t=0,-"S
9.Total Sven depth below land surface. 8 Do A) 24a. Submit this foray within 30 days of completion of u
Formultipie urtir lat all deptlsr ifdiffermt re=nrple-3@200•and 2@1001 construction to the following:
10.Static water Level below top of casing: 430 (ft.) Dfv'isi6 of N rater Resource;,Inthrmation Processing Val%
lftvaterlava!it show carin&tree' I&Mall Service Center,Raleigh,NC 27699-1617
11.Borehole dfamemr: (tn.) Z4b.For Iniection��'t%1[s: In addition to sending the form to the address in.
above,also subrait one copy of rhis farm within 30 days of completion of v
12.Well construction method:
C"auger,rota cable.direct push,ate.) !` constructioa to t2se followine:
ry;
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Division of F;'aterResources,Underground Injection Control Prom m
FOR WATER SUPPLY WELLS Os ILY: (�� .� 1636 Mail Service Center,Raleigb,p1C 2 7699-13 6 6
13a.Yield(gpm) �_ ;\lethad of test: 3.YW� 24c-For WaterISuboir&Injection%Yells: In addition m sending the fort
the address(es) al�ova,- also submit one copy of this form within 30 day:
13b.Disinfection type.� Amount: completion of well;construction to the county health depart°tent of the cot
where eonstruetea '
Form WNI-1 ?North Carolina Depanmcmt of Eaviranm.-nt:1 Q:aiity-Divlsior.o£t:rcr Rcscumc3 21-: