GW1-2023-01515_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD (GW-21 For Internal Use Oaly:
1.Wall Contractor information:
Russell Taylor 1 14.WAT ZONES i
FROSS TO ; DESMUPTION
Well Contractor Name
2187-A 1158 f4 f tL f 79— r!
NC Well Cotmactor Certification Number �g f c a�IN �t
TS.C13TF:R CASIIHG r mnl@•eased wells)OB:L7NER{tf eMtie
Hedden Brothers Well Drilling, Inc FROM TO l DMAIaI= THICKNESS MATM11a.
fc ft In.
Company Name I '
PP,, L,-99 nn I6.INNER CASINGORTOBOM ermalalmcd-lea
2.Well Construction Permit#. O&D"1 -P FROM I TO ; DL1tiiECEA iHIt�G�tESS �TAtER1AL
LUt al!applkable%cell r=m=Udn permits(.a WC.County.Stag Variance.eta) � � I '(lo tb & ". Y
3.Well Use(checkvvell use): 1ptt. I n t ,a, . 88 LEI E L
WnterSupplyWeiL• FROM t REEITo 1,DWILT'En SLOT SIZE I THiCtflvM MATERL'1L
Agricultural E)Mtlydelpal/Public ft, ft. �-
C9eothertasl(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. is
Industrial/Commercial DResidential Water Supply(shared) MB.GROUT
Irrigation FROM TO MATERIAL I MtPLAM1MTMMODS.L%tOLi`T
lGeothermal
n-Water Supply Weil: fL I 20 cvaee�a I plan0e!
onitoring �Reeovery m EL
ectlon Weil• fLquifcrRccharSc MGtotu%dw?tcrRcmcdiadon19.SA.,MIGRAVEL PACK if a livable)quifer Storage and Recovery Salinity Barrier FRost To SL4TERIAL Evtrut�tct>:vT� oa
quiferTest MSMrtawaterDrainago It. Ifoxperimental Technology Subsidence Control ft.eothermal(ClosedLoop) Tracer ZO.DRILLIsYGLOG anschadditionalabeetsifa(Hea' Ccolln Return) Other(eX lain under 21 Remarks) FROMI TO' p ' I DFseRIPT10\Icolor.t,�rdneu�ontroekf�t'a�rirn aiu ecal
1��7 fL I Gay S sand
d.Date Well(s)Completed: o`f Os1,3 E�'el!ID# i , in it I granite
Sa.Well Location:Mu-
ICl
Facility/OwnerNinne FaciliryID�-(ifappGeabie) i fG ft. i F' ,%
Physical Address.City.and Zip
/r/nNo �IRiVTI� LJp�p�9�7ot I 'I.R£SL►RF(5 -si
County Parcel Identiftcadon No.(PLN) '
5b.Latitude and Iongitude in degrees/mmutes/seconds or decimal degrees: 1 - -
(ifweU feeld,one iat/iong is sufficient) 22.Certification:
35° l.3. 0�5 IN 063° a 4-.OR& w a
6.Ware)the well(s) Permaneut or [)Temporary siparare ofCcrdficd NVclt Contractor D
ad
ay signing this form,1 hel reln certify that t rrtU(sJ�rar(irnr)wa trurled in aetnrda.
7.Is this is repair to an existing well: QYes or No ttdtlt 15.4 NGiC 02C.0100 ar ISd,YCAC 03C.OZ00 Jf'rl/Consatrerion Smrdardr and do
Midair tt a repair,fdl oat knontt%vrll construction taformadan filezpvlair the aatum of the copy of this re=rd,1uw been pratidrd to-!-curl!oxmer
repair mtder;till mnarlaseetion or on the backofthIsfarm. 23.Site dfagraril or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back o€this-page to provide additional welt site details or-A
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of Wells construction details. You may also attach additional pages if neccssaty.
drilled: /j SUBMITTAL 1N$-MCTClOIgS
9.Total well depth below land surface: ft) 24a. For-411 li'eU Submit this form within 30 days of completion of«
For multiple i rl&rest all depth-ifdierenl(example-3Q300'and 1Q1001 construction to rho following:
I
10.Static water level below top of casing- �® —(fr.) Division of}Pater Resources,Information Processing Unit,
Ifwater lttwl!r ahOW casing.Use" I b17;•Tail Service Center,Raleigh,NC 27699-1617
11.Sorettole dtaarerer. (la) 34b.For Inieciion veils:- In addition to sending the form to the address in.
L j� 1L� above,also stttimit one copy of this forte+�ithin 3o dot's of completion of
12-Well construction method: 1�CJ�1 construction to the foliowin_e:
Cio-auger,rotary,cable,direct push.etc.)
Division of,�Vater;Resources,Underground Injection Control Program
FOR WATER SUPPLY\YELLS OARLY: 11636&Mail Service Center,Raleigh.VC 27699-1636
13a.Yield(gpm) �.� 13ethod of test: 24c.For Rater Suoofv&Iniection Wells: In addition to sending the fore
_ the address(es), above. also submit one copy of this form within 30 tiny.
I3b.Dlainfeetivtt npe: Amount compaction of.well construction to the county health department of the co,
where eonrsaueied. I
t
Foam OtV-1 Non;t Carolina Departtaamt ofEavi-mrim:mal Q:.cih -Di Wo::of e:atar Ra—Mcs Revised 2-2_-:
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