GW1-2023-01513_Well Construction - GW1_20230209

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W_-_,_ELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Russell Taylor 14,WAT&RZONF.S i
FRON_I_ TO 1 l I DmCRIFrION
tvcll CoanacrorName 4-3 � f �{•-8 � —a0
2487-A fc. ft.;06 - r73
i6o
SIC Well Conawm Catitiiwtion Number Is.OUTER CA MQ for meltl-cued wm3Ls ORLUiER(If le
Hedden Brothers Well Drilling, trio rltorl To' Dlant R TMCIOM MATIMIAL
Compimy Name
n 16.LYNER CASING OR TUBIlVG thermal eloseddoo
I.Well Construction Permit: f QY1 e�0— - FROM TO! DuhtETsa i Tmcmvm blATOJAL
LM all applkabir troll ranswedon pernifts(.a WC,County.Stag Yariance,eta) 0 tt. 1 n fn. PVC,
3.Well Use(check well use): ,2 tr. 144 T° Lp "' Tat
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upply Well: 17sCREFu\FROM TO i i Duhre2'IaeR SLOTSIZE THIC�.IESSultural E3Mlmicipal/FubIic fa ft.; imerasal(aeat(reptcoolins Supply) OResidentiai Water Supply(single) fG ft.;trial(Commerciai E3Resideatial Water Supply(shared) GROUTtIOFRODc TOI StATEAIdL I EhIPLt:C M-17ater Supply Well: 0ftIzo n- �atrY n f aumaed
toring Recovery m tt.
n WeTi: fr. I fL
fer Recharge MGroundwatcr RcmediationI9.SAND/GRAVELPACK fro Ue2blel
erStorage and Recovery 3'•Satinity Barrier ARA To NIATERULftTest OStotmwaterDrainagerimental Technology5ubsidence Controletmal(ClosedLoop) D-Traccr 20.DRILILNGLOG attschadditionalsfieetifn
ermal(Hen CDolin Return) Other(explain under#21 Remarks) FROM TO' I DESCRIPTSSiN Im1or.hasdacs soafrart:esu�tram eta.ett.l
f• � 3� �� I clay sand
4.Date Well(s)Completed: 0 D Well l Di: j " f` granite
Sa.Well Location: f ft. ft.
f I i ft. ft. I 6+ �_Vol Low"
Factlity/ownerTtatoc Facility lmT(i£applfcablc)
loiti5 -OV'--ea.
Physiear Adders.City.and Zip
m
t locoN WU t I � ^Y7.'1991n '1 RE.�TARI6 s3tr:'l%t.r�r�
County Pored Idcadhcatiaa lNo.(PL\t
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees: )
Lifwcu Hopi,one 140ong is sutlicicat) 22.Certification: j
A-5a 1a.398 '�&(305 W ,01614 �1 i a�23
ark
fi.Is(are)the yell{s} Permanent or Tentporar} Sigaattuc ofCcrdficd Well Contractor D
a signing this farm.I hereby cc,•tify thata+all(sI sits(�retr)eeactrvered in treeardai
7.Is this a repair to an existing well: [3Yes or No a irlr IBA NCAC 0k.0100 or U l NCAC 02C A200 Nell Cunstmedan Mandan&and Ilia
/f tlrrs Is a rrpair fdl oyt 4noan tvrll eottrtruetloe Enforararioa _ttsesplain the catum of tire rop}of this racardJtas boon praridrd ro tke Drell o�,�rer.
repairrmdrr 9-71 remarkeseetion or an rite back offItisfamr. 23
a.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 w
constntction,only 1.GW-I is needed. Indicate TOTAL NUMBER of yells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTR' UCTIONs
9.Total well depth below land surface: d.5bo —(ft-) 24a. For A]l tii'ells: Submit this form within 30 days of completion of w
For nurltiple r,rlls list all depths rldi frrent(examplr-3@?00'aand 22@1001 eorsmaction to the following:
10.Static water level below top of casing: 7 y (ft.) Division 0f Water Resources,Information Processing Unit,
f/'ivamrlawl irahow C=bJn use"+' I617 bTail Service Center.Raleigh,NC 27699-T 617
11.Borehole diameter. (t1L) 34b.For Iniec[(on Welts: In addition to sending the form to the address in:
above,also submit one copy of this form within 30 daya of completion of t
12.Well constructiod method: t�1 construction to the fo,11oR•ia_e:
C"auW,mtvy,ably diecot push.etc.} �—
Division of Vi'aterResources,Underground Injection Control ProFrma
FOR WATER SUPPLY"YELLS ONLY: L636 Y1aiF Service Center,Raleigh,IiC 27699 2636
13a.Yield(gpm) 1Iethod ofteSC 34a For Water Suonh•&Iniection Wells: In addition to sending the fort
the address(es) aboie, also submit one copy of this form within 30 day:
13b.Disinfection type: Amount,. completion of veil construction to the county health department of the cot
where eonstrur; i.
I
Form Revised=-�