GW1--03430_Well Construction - GW1_20230518

. WELL CONSTRUCTION RECORD (GW 2) i
For Internal Use Only:
1.Well Contractor Information: , . 1 •
Russell Taylor 114.WATER ZONES f
Well ConnactaaNum I FROM I TO 1 DESCRIPTION
2187-A I qo f` I q5 3'lo -ar15
NC Well Coatractar CertiSeatien Number .50
5
ft.
G 6 O
1 IS.OUTER CASING(for multi-cued wells)ORLI ER of ) •
Hedden Brothers Well Drilling, Inc I FROMTO I DIAMETER THICKNESS MAITRLILL
fr. ft In.
Company Name
116.INNER CASING OR TUBING(geothermal eioseddoon) •
1.Well Contraction Permit#: I FROM I TO DIAMETER l TEIC LNESS NATERLAL
Lim all applicable wall constructlon permits(i.e.ilrC,Cormry,State,Variance,etc.) I• 0 fL 1 88 ft. /,,, in.
le
3.Well Use(check well use); .88 f t• I C�O tt ��(ov✓ tn' I • 18 8 ``vrs L
Water Supply Well: 17.SCREEN
• FROM I TO I DIAMETER SLOT5IZE TRICICOMS MATERIAL
Agsicultuial OMunicipal/Public ft. ft. i is.
MGeothermal(Heating/Cooling Supply/ 5DResidtnrtial Water Supply(single) ft. ft. I in.
Industrial/Commereia1 Residential Water Supply(shared) 1&GROUT
irrigation • FROM l TO i STATERLIL t RM?LAC&vIE\TSEETHOD&A.�fOttr\
Non-Water Supply Well: ft.
I zo �w cn�a I otanvott
Monitoring �Reeovery ft. rt.
Injection Weil:
ft. 3.
Aquifer Recharge Q Groundwater Rcmediation
Storage and Recovery19.SAND/GRAVEL PACK(iif anolieable)
SaiinityBarrier FROM l TO I �LITERLLL I £STPUGII1f�Z]tErFtoa
Aquifer Test DStormwaterDrainage fa I to I i
Experimental Technology Subsidence Control l tr. I n I
Geothermal(Closed Loop) DTracer 20.DNt f t. NG LOG fennel:edditiottd sheets if neemwy}
macr
Geothermal(Heatinlr/Caoliag Renrta) Other(explain under 2l Retaatis) FROM ! TO I DFSCZi1PTTON teolon hatdaea 7oiarec Icer ante Ace.teen
�l/iaJr2ot
0 fr. I SO ft. I day a,sane
T
4.Date Well(s)Completed: Well ID# 80 tt. 595 .fL I granite
tr.
Sa.Well Location:
Ream,' �T l I i I r... '' .-a i•'i ......6 r
Faelllity/Own \tame Facility IDR(if applicable) 1 ft. ft. `"s r t t-` y— i.
e2l�1.O (` (',rK.. Rd• Blom CAS a8�t3 i f,_ i re. MAY 1 R 7023
Physical Address,,1 and Zip I / A 1 .,�+ d rI 1 fr. ft.
1LL f1 �Q U4 41 LO(D7.5O1�71,3 /Cot 21.REMARKS l of t'F7; ;r 71 r't n^_,s;;,•,'.5 I i t:1
1 D:'at r��L
County Parcel Identification No.(PLC t
Sb.Latitude and longitude1
in degreestmiaatestseeoads or decimal degrees:
(if well field,one(at/long is sufficient) 22.Certification:
35D .2A.(0q I ,i O83° ale -900 w iee.0.4.40 - 13
6.Is(are)the wdU(s) Percnanent or Temporar} Simatutc ofCcn(ficd WellContractor�� Ai-a
3y signing this form,I herebycertify thatcgre-e_
rills)was(were)comtre red at=and&
7.Is this a repair to an existing well: Q Yes or No with ISA IvCAC CC.0100 or ISd,VCAC 02C.0200 Well Construction Standards and th
If this LT repair,fill out L'nowa well eonstrnation information aesplain the nature airily cop'eats record hm been proridcd to the'tell ouster•
repair under 52I remarks sntion or oar the back of this famr.
13.Site diagram or additional well details:
3.For Geopr'obeiDPT or Closed-Loop Geothermal Wells having the same You may use the backof this page to provide additional well site details or
construction,only I OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: tr/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5a 5 (le.) 24a. For All Wells: Submit this form within 30 days of completion of 1
For multiple wells lift all depths yore-emit hramplr-3Q200'and 2Q1001 construction to the following:
10.Stacie water level below top of casing: r10 (fr.) Division of Water Resources,Information Processing Unit,
//runner local is above casing use'•=-" 1617 Mail Service Center,Raleigh,NC 17699-1617
11.?Sor'eho1e diameter. LO (In.) 24b. For Injection Wells: In addition to sending the form to the address in
abo�•e, also submit one copy of this form within 30 days of ce,opl.een of•
11.Well construction method: a; JL. Q (� ! construction to the following:
04.auger,nasty,sable.direct push.etc.)
Division of Water Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 2769 9-1 6 3 6
13a.Yield(gpm) .q0 Method of teso Elialip 24c.For Water Suooiv 8 Iniect:ion Wells: In addition to sending the fon
�� �} the address(m) above, also submit one copy of this form within 30 day
I3b.Disinfection type: YS rr4 Amount: t Ld"'"t 1 completion of well construction to the county health department of the co
4... where constructed.
Form OW-i North Carolina Depayment of Environmental Q:.sii.--Division of P:stet Rc0127c= Revised 2-1-
Ii