_Well Construction - GW1_20230320 (54)

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Prlt9t
. WELL CONSTRUCTION RECORD (GAY-1) For Internal Use Only:
1.Well Contractor Information;
Russell Taylor 114.WATERZONES
Well Connector Name
FROM I TO I I I DESCRIPTION
2187-A ': 103 fa 110 R 1 fL 145-150
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YC WeII Contractor Certification Number155 ft. 110615.OUTER CASING(for multi•ersed wells)ORRLI 4ER(if obi) •
Hedden Brothers Well Drilling, Inc FROM 1 TO DIAMETER THICIOOESS l MATERIAL
ft. I ft In.
Company Name
�/J� r + j + 116.LONER CASING OR TUBING(geothermal closed-loon)
2.Well Construcdon Permit#: `•X_- 110�'f/4'• 9- 1 I I I I`I' I FROM I TO DIAMETER I Taub MATERIAL
Litt all applicable well corttteuc#on permits(.a WC,County,State.Variance.eta) I• 0 t1. 13lt) ft' l/_ In. ' PVC..
3.Well Use(check well use): -'3 Lo £t I ;8 fit o ' . 188
188 n*Y E L '
Water.Supply Well: 17.SCREEN a7
• FROM I TO DIAMETER SLOT SIZE TRICICt MATERIAL
Agricultural uMunicipa1fPublic ft. I ft. in.
Geothermal(Herding/Cooling Supply) figtitesidential Water Supply(single) ft. I ft I io.
IndusuiaVCommereial DResideatial Water Supply(shared) 18.GROUT
Irrigation • FROM I TO I MATERIAL I EMPLACMIENT METHOD d AMOUN
Non-Water Supply Well: 0 ft I zo ft I .a rae�a I peeped
Monitoring oReeovery rt. I rt. I
ejection Well: - -
Aquifer Rcc fL I ft I
Aq Itargc �GtvuladwztcrRcmediation
19.SAND/GRAVEL PACK tiCaaalieable)
• Storage and Recovery DSalinity Barrier FROM 1 TO I MATERIAL. 1 EMPLACEIIIWTStErnOD
Aquifer Test oStorrawater Drainage ft. I ft. I
Experimental Technology Subsidence Control I ft. I £L I I
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Geothermal(Closed Loop) Tracer 20.DRIIJZNG LOG(attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) fOther(explainunder±21 Remarks) FROM Ito I DESCRIPTION(color.hatdneasoWrecJettp..ersiosta etc/
L_ 0 fr. I ^AQ ft'
I clay&sand
4.Date Wells)Completed: aIIJ�/a�73 Well ID (A ft �(�f�po f` I gas
Sa.Well Location: rt. ` t {
�/tom ' ,N
Te-te �AtciMQI1 i fr. I fit I-- :: *y�:I,.
Facilfty/OwncrName Facility Inc:(if applicable) ft. ft. I
305 Lake. D . ei.ol.oltl.ee.., a?Rieu ft_ . t:. I (vIAR 2 0 2023
Physical Address.City.and Zip ft. I , ft. I _21.RE42ARICS In7c7,.":1i;�1 P'....._ .:2 t::.:�
ifkete.SoN Coua r. 95(p3-07-158o Cil;a. 0t:i
County Parcel Idancifteatton No.CPL0 '
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ist/iong is sufficient) I3.Certification:
36° oq.A.?9 N 08i° DB . g101 W /�7�-] ay 1(o Oa,6.Is(are)the well(s} Permanent or DTemporar}' Si mtltr of Certified Well Conffdeier Dater
3y signing this forum,I hereby certify that t.miffs)was(were)catutrneted in aaardi
7.Is this a repair to an existing welt: DYes or No with!SA 3tiCAC 02C_0100 or 1S.4 NC.4C 02C.02001fell Construction Standards and aIf this it a repair.fill out known well construction informatione'eaplaia the conic of ihr copy of this record liar been provided re the well owner-
_ _ repair under021 remarks section or on the back oft/usform. 13.Site diagram or additional tt21I 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'
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.TotaI well depth below land surface: c20 0 (ft-) 24a. For .411 Wells: Submit this form within 30 days of completion of
For multiple wells list all depths!fdifferent lexamplr-3(Q200'and 2(0l0D') construction to the following:
10.Static water Ievel below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
!twofer level is above eosins,use'•=" 1617 Mail Service Center.Raleigh,NC 176994 617
I1.Borehole diameter. f3 (La.) 24b.For Iniection Wells: In addition to sending the form to the address in
„ - N r.,L3 ` above,also submit one copy of this form stithin 30 days of con platioa of
IZ.Well construction method: �(J[ �(��-3.1- construction to the falioaine_:
(Le-auger,rotary.able.direct push.etc.)
Division of Water Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC Z7699-1636
13a.Yield(gpm) a95 Method of test: &IMO 1 24c.For Water Snooty&Infection Wells: In addition to sending the lot
the address(es) above. also submit one copy of this font wi hin 30 dr.
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13b.Disinfection type: L Amount: . tt LQ G,s completion of well construction to the county health department of the Cl
C: where constructed.
Form OW-1 North Carolina Depara.,tot.of Ecvromran:ai Q:.aiity-Di v ior.07.-accr Redress Rtv 2-22