GW1-2023-00788_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Intemal U�e On IY
1.Well Contractor Information:
Russel Taylor 14.WAMM ZONES I !
Wen Contractor Name -may`, ^'y 5`)tf tom,a1 aFAOSl TO I kl I DFSt:RiPSfoF
2187-A ,a�: "do s
MC Well Contractor CatificationNumber JAN i 2 2023 15.CT'=CASMG tbrtntatieatedwells ORLMER cible
Haddon Brothers Well Di lliilg, Inc .FROM To I r DIAMETER THICICYESS MAT6RML
terra.:x ':ydi 1,." ft. ii ln,
Company Noma
i6.1NNER CASING OR TQBING eothermal eloseddao
2.Well Construction Permit#: FROMTO ! DL111Er£R I 7MCLN-M I MATERML
LtV all appllta6(r urll cnnstrurtian permits t en&M.County.Stara Variance,eta) it. 144
It. 10 to. 18 O T t
v 1.
3.Well Use(check welt17.
Water RMN
Supply Well: FRaaC Ta l Dtna»:rt R sLorslue Tluci ss arrt7z RUL
Agricultural MMtuticipaMblic ft [, ft. ? in.
Geothermal(Heating/Cooling Supply) DR.esiderrdW Water Supply(single) ft. f ft. Im
Iadusuial/Commareiai Residential Water Supply(shared) I
uPP Y i&GROUT i
Irrigation tion FROM Tat MATMUL 151PLARSINTh ETFiOb d:.L1tOGl'T
Noa WnterSnPPI3'Rre1L• fT I zd
Monitoring Recovery fr. i ft.
njeCtion Wail:
fL ` fL
Aquifer Rcchwgc E20noundwatcr Rcmediation
or Storage � I9.SANDlGRAVEL PACK ff a livable)
and Recovery M-Salialty Barricr FROM To+ ataTERtu. P�tPu�nt �Tatsrlroa
Aquifer?est [3StormwaterDrainage
Expetitaetual Teehnolory DSubsideace Control fr. st
Geothermal(Closed Loop) �Trdcer 20.DRILIMN- GLOG sus additional3beet:ifn
Geothermal(Heatin oolin Rearm) ' Other(explain under n1 Remaris) FROM TO t DESCRIPTION leofon furdoeamnteeek sire etat
r C� clay S=,%d
4.Date Well � ,,,,'�s)Completed:l�� XVell IDS ft. I I rt. grtliL
So.Well Location: f`
MAtnd S O.sr woe, I LC
Facility/OwnetNatm Facility IDS(if applicable) ft. i I
Nlav�y N,(� Ntal+l-awls 287141
Physical Address.City.and Zip
N1AcoN 3Ty =1.RESIARKS i
County Parcel IdeatiScarion No.(PLti i '
Sb.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(ifwatt Bald,otle 140ong is MiNcicat) 22.Certification:
350 ooA 7 0e3' 19.1008 W lam►�aQag
6.IS(are)the wen(s) Permanent or 0;Temporaty Simratureofcen(fiedWeliContra= Dmc
1� ay r.'gnrtrx This JorIr:!herrbs errrify fhar t urll(s)Mrty(were)eatsTr=d in aewrdat
7.IS this a repair to as esigbing tveII: [3Yes or A'o uitlr lSrJ NCRC 0.3C.0100 ar IS.4 rVCAC 03C.OZOD!fell Canrtrretlon 9aadsrdr sad 11tE
{'this is a repolr,fdlour.Fnown wrll eonsrnretlon fnforntatlonP-71emplaio the nattrr ofrlrr copy of zhb record!;=been pro ided ro the uail auger.
rcpalr Under 531 t•rmodasecrion or on the back offlrtrJtum. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use Ibe back of this page to provide additional well site details or w
construction,only I GW-I is needed. Indicate TOTAL A*UMSER ofwcIls construction tier ltls.You may also attach additional pages if necessary.
drilled: p SUBIAMAL IN TRUCTiONS
4.Total well depth below land surface: A o� (ft-) 24a. For AlI Wells e Submit this form within 30 days of completion of W
For multiple arllclltr all depthrirddrrml(rsamplr-3@300'and3@1001 construction;a the followin&
�+ t
10.Static water level below top of casing: �"1 (ft) Division of water Resources,Information Processing Ual%
0-ter Laval irahow Basin&trsr-_,. 167 Ma tit Service Center,Raleigh,NC 176WI617
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11.Borehole diameter. (rm) 34b.For Iaiection N'et11s: In addition to sending the form to the address In.
12.Well coasts uctiori method: above,also submit brie copy of this form wfi3fin 30 days of completion of c
>t• I } constntc cu.to the fallo%ving:
(ix.auger votary,eablo.direct push.ate.)
Division of�21aterResources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: Is36 Mail Service Center,Raleigh.NC 2709 I636
136.Yield(gpm) Method of test: 34- For wat!r Sulopiv&Iniection Wells: In addition to sending the forr
_ [[ ,he address(es) ab
i3b.Disinfection type: Amount: ove, also submit one copy of this form tvitbin 30 tiny)
l completion of Well construction to the county health department of the col
inhere coastruet�d I
Form Glt'-1 North Carolina Depanrrant ofEa�i an=r cnczl Q:siit.-Di �n of�:'arer Rcsoa ccs Raised='��':
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