GW1--05284_Well Construction - GW1_20230814

. WELL CONSTRUCTION RECORD (GW 1) I For Internal Use Only.
1
1.Well Contractor Information: -
Russell Taylor xNR; 14.WwzoNES i I
• ? FROM I TO I ' I DESCRIPTION
WeuCaaasetmNa»� i ia5 re' 1 no if" I 7-.43Q 333-eg3R
2187-A •
1353 fL 1358 J I 4a—N-4.51
NC Well CoatrsGar CathiCtCaa NIumber IS.OUTER CASING(for maiC.nsed wells)ORLINER Of���
Hedden Brothers Well Drilling, Inc ; FROM TO DIAMETER THIC1O ESs 1MATERIAL
I- ft. ft: In.
Cootpaay Name •
16.LRVE&CASING OR TQBING feeothesmal closed-loon) • -
1.Well Construction Permit#t: FROM I TO DIAMETER. I THICR'VESS MATZIDAL
On all applicable null eotlmaetloa permits(La.UTC.County.State.Variance.etc) . D n 110d ft•• to tn. ' Q\/es
3.Well use(check well use); i/aa Tr' I /C&P ft. 1 to in' . 188 TE L t
Water Supply Well: ! 17.SCREEN
• FROM I TO nIAMMER SLOTS=ZE THICKNESS MATERIAL
Agsienitttral • UMullicipaUPubfic ft. ft., to.
Geothermal Meeting/Cooling Supply) aResidential Water Supply(single) ft, fr. I in. 1
lndusniaVCo escial I DResideatial Water Supply(shared) 1&GROUT -
lrriaation • FROM I To I MATERIAL. I EMPLiCSI T METHOD&AMMO.-
Nan-Water Supply Well: I 0 ft I zo tL I COMA e=... I vearoad
Monitoring DRecovety !j ft. I ft. `
jeetton Well: 1 ft. , ft. I 1
Aquifer Recharge 0Grouadwrztc:Rcanediatioa
19.SAND/GRAVEL PACK(if apers able)
Storage and Recovery 0Satiairy Barrier FROM I TO l MATERIAL 1 EMPLAC13rrMTMETHOD
Aquifer Teat OStormwraterDrainage ft. f` 1
Eltperimsasal Technology ! 0Subsidence Control I ft. I ie I
Geotheffial(Closed Loop) DTraeer 1 20.DRILLDiG LOG(attach additional sheets if aeewarf)
FROM I TO I OFSGAIPTIONNteelonharieeaeotthxtteaaeeleftmm. $
Geothermal(Heaaag/Cooliaft Rctuta) Other(exalain wades Zl Iiemads) o rr• i q j I ft. day b sane
4.Date Welt(s)Completed: r1 a5 Well•lD 1 q4 t` f 4500 ft. granite
Sa.Well Lome on: ft. ft. � " yr`." !"•
i,A _ /ii:'') F j -
.
_aA
ft. I t�,r
ft.
Frail ILIin Farms I AUG
Faa a lity/OwaNaroa PaeilityIDd(if applicable/ ft. I ct. I z_, 2023
LtlesF I ioai I. �-11n (QB 1734 I t� I `� IT't._;�;;. �-_,.. • y ut:t
fc. I ft. I DW3iPti'lt
P6yrical Address.City Zip I 21.RENAME
S
M -1i Lai 4-8833914
County Parcel Identification No.(PLC 1
51s.Latitude and longitude In degrer-s/tainuteslseconds or decimal degrees:
Of well field.one ln'loag is sufFcicat) 7.2•Certification:
35° io.&35 ; N 083° a3• W - /.. am).#0a.
6.Is(are)the wells) Permanent or Temporary Si�raturc of Certified Well Contractor
By signing:his form.1 herrin eert fy drat 1 svell(r)was Oren)eaamaaed in=gni
7.Is this a repair to an eei.ifiag well: D Yes or No u:tit 154?CAC O3C.o100 or IS.d VC4C 02C.0200 Well ComasrrNtm Standard;Gad 0
If this!r a rep:in fell cat!mown w 0 iwlf esratlan infarma:Ion d'esplaie the nature of the copy ofthis record nas beers provided to the well omen
under 021 remarLsse tiara or Cuthe bad-of this form.repair 23.Site diagram or additional well delude.
You may use the back of this pace to provide additional well site details or
S.For Geoprobc/DFT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ( SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5""}Q (f.) 24a. For All Wells: Submit this form within 30 days of completion of
Far mrittplr wells rate all depots((different t'rsamplr-3@200'and 2(01001 construction to the following:
10.Static water level below•top of casing: ) 5 (ft.) Division of Water Resources,Information Processing Unit,
.l'wotm levy!it above easing,use- •• 1617 tilall Service Center,Raleigh,NC 176994 617
11.Eorenole diameter. C 0 go.) 34b. For Infection Welts: In addition to sending the form to the address it
above,also submit one copy o£this form.sithin 30,days of completion of
12.Well construction method: fC, ��.�LL C/�Ll eensmtetion to the following.;
(i.e.211aST• ary rot ,able.diteet plait.etc.) v
Division of Water Resources,Underground Injection Control Prograt
FOR WATER SUPPLY WELLS ONLY: I 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) la Method of test &CND '-'*c•For Water Sunray g Infection Wells In addition t0 sending the above. fo
the addressees) also submit one copy of this form within 30 dal
\3 13b•Disinfection type; 1 t4 ;mount: i (e i completion of well constuetion to the county health department of the e
1 V where constructed.
Form OW-1 North Carolina Department of Envi:onr..:a:al Ql.aii.•-Di:i io.-.o`IWvar Raoac.e Revised 2-I