GW1--03459_Well Construction - GW1_20230518

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. WELL CONSTRUCTION RECORD (GAY-1) } For Internal Use Only:
1.Well Contractor information: t 1
Russell Taylor ; 14.WATERZONES
Well Comae;Name PROM I TO I DESCRIPTION
2187-A fa I I I
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NC Well Cottzrxtor Cettifiuriea Nmabet 15.OUTER CASING(for molts-eared wells)ORLINER Of��
Hedden Brothers Well Drilling, Inc I FROM To I DIAMETER I TRICICOISS I MATLRIAL
fr. fr. I tn.
Company Name
16.DINER CASING OR TUBING(Beet gr zl closed Moo)
I.Wdil Construction Permit#: eita3 a7"j,j- q-141/0 76) I FROM I TO I DL.METER I TRIMMER MATERIAL
Ctrs all eppteable wall eorttrroetton permits(i.e.C C Cotmty,State.Variance,etc.) I 0 it. { ft. I la. 1
3.Well Use(check well use): i ft. I ft.
Water Supply Welk 17.SCREEN
FRO MI TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 � u M MunicipallPublic fn ft. lc.
ZGeotficaul aleatinglCooling Supply) MR.esidential Water Supply(single) fr. I ft. I to. I. I
IndustialiCommtxeial DResideaaal Water Supply(shared) is.GROL•T
IrTiltitlon FROM I TO I MATERIAL 1 ZMPLit�v17_tMETHOD&A MOISN
Non Water Supply Well: i ft.
I m �- �v a eQm pranged
Monitoring �Rccovery I ft. { Ft. i
jection Weil: t is I it.
r
Aquifer Recharge GrouadvcatcrR.cmediztion
Stange and Recovery19.SAND/GRAVEL PACK Cif aTER/ble)
$aliII$y Earner PROM I TD I MATERIAL ( ntstrL►t�t�rTSUTHOD
uifdrTest OStormwater Drainageis to I I
Experimental Technology DSubsidence Control ! fr. I ft. I I
I
Geothermal(Closed Loop) Ttaeex 20.DRII.LI:�G LOG(attach additional sheets if aeeesnat!)
FROM ! 30 I 0EsCRXPTTON teolor.hardness eoUtroektepe grate size.eel
Geothermal(Headng/Cooliaglletort) other(ezptaia wader.zi Remarks)
0 fr. i ft
I 12622
Gay b sane
4.Date Wells)Completed: �-lot Well m# it. u. I yraaraSa.WelI Lomoon: 111 ft. I , ft. i ['" .I--( a fi`c i 1./ .t_)
fa
I ft. I MAY , 8 2023
ry tssae Facility ID�(ii applicable) I ft. ft. I
5o Lohi'k.-louiLrvoli Wi,i-Ifiav- car/el Ir. I :L f
..- pn.,.o•' ' i 1_11 ea
Physical Address.City.and Zip Car'3t�/7 f { I e w; r '
r7 I fr. , t.
J ctct r eau Ty /& i o r Ake.,81(0 V ; 31.Rs-MARRS
County Parcel idcndfreatiec No.(?i '4( I)&IL.L n t,PEQ (3004. —8004•)
5b.Latitude and longitude in degrees/miauteslseconds or decimal degrees: I
(ifwd field,one lnt/iong is sufficient, ??Certification:
35° „?D. 54o N 083° 1 B. 6 r1" w
_,t,(/J.4.e..,QP ,....3 4 6.Is(are}the weil(S} permanent or Tetnparat}, SigsmtureofCctifedNall Contactor
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By.rgning:Ids Jane.I hereby certify that t I
well(s1 eras(Ural constructed in accords
7.Is this a repair to an existing well: DYes or Na with LTA NCAC 03C.0l00 or ISA,VC4C 02C.0209 Well Construction Standards and th.
if thin Fr a repair,fill out Moen well eonsrruction tnfarmaian ctespiain the rsa:ur_gfthe copy oftis record hat beery provided to the retl onw.
repair tender 021 remarks section or an the bad ofit:1;11rm. 13,Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may us;the back of this page to provide additional well site details m
construction,only I OW-I is needed. Indicate TOTAL NUMBER of wells
canstrucdor,details. You may also attach additional pages if necessary.
drilled: l * SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Soo (ft) 24a- For All Wells: Submit this fort within 30 days of completion of'
For multiple wells last all depths ifdifferent tisarrplr-3Qa 200'and 2 r@l00'} canstrtction to the followinm
10.Static water level below top of casing: 75C) (ft.) Division of Water Resources,Information Processing Uatt,
.(tamer lava,it above easing.use-=- 1617 Mall Service Center,Ralei;b,NC 2769 9-1 61 7
11.Borehole diameter. ¢a.) 34b.For Infection Wells: In addition to sending the form to the address in
12.Well construction method: j. above,also sobrnit one copy of this form within 30 days of complexion of
its auger,rotary,cable.duvet push.etc.) construe-Ice to the foitoniag
Division of Water Resources,Underground Injection Control Progrea
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 2769 9-1 63 6
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ISa.Yfttld(g}rm) ' Method of &cup l 2-4c.For Water Supply&Infection Wells: In addition to sending the for
fs rr ! the address(es) above, also sobrnit one copy of this form within 31 day
I3b.Disinfection type: �S R Amount: (l e -} I completion of well construction to the county health department of the et
!.,. where eonswuct d.
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Form OW-1 North Carolina Depar-ent of 5-airanr..:raz1 Q�ii.•-Di:sioe ofti:s.er Resound R.vised 2L