GW1--05285_Well Construction - GW1_20230814

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. WELL CONSTRUCTION RECORD (GW-1' For internal Use Only:
1.Well Contractor Information: •. •
Russell Taylor 1 1 14.WATER ZONES
WW1 Comma Norm I • t FROM 1 TO I I DESCRIPTION
2167-A 1 qi rG 11oa n 133-136
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1495 ft* a9n_.
NC Well Contractor Catificltiea Number t Is.OUTER CASING(tor multi.asedwens)INCLINER Of .
Hedden Brothers Well Drilling,.
Inc 1-Flloai I 'ro DIAMETER TNiCICIESS l M► uL Company Name 1
116.DINER CASING OR TURING(geothermal elosed.iooP) •
2.Well Construction Permit#: 0? Q,-a I84 -9- 1113l 8 I FROM I TO DUatE ER 15UI JIZS MAt IAL
Uri ail apptttabte we mermanpTmits(r a WC County.Stag Variance,etas) {. 0 ft I ?3 .11. to in. PYC.
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3.Well Use well use
):re): � ft. 1 75 ft.73 La ire. . 18 8 s rEEL.
Water.Supply Well:: 17.SCREEN
FROM I TO ` DIAMETER SLOTSIZE T> MATERIAL
pgreultural LiMunicipal/Public ft. 1 ft. I in.
Geothermal(ileating/Coolius Supply) MResidential Water Supply(single) ft. ft. I io.
IadustsiaVComnsereielResidential Water Supply(shared) 18.GROUT
Irritation I ' FROM 1 TO I MATERIAL I EMPLitnt)1rMtruoo&AMOt+N:
Non-Water Supply Well: 0 ft J Zo ft' 1 "''"'r3 I pumped
Monitoring , DRecovery II 2 ` fr..
F:ven;
! It
ahazgc t'sroundwz[cr Remediztion 9.SAND/GRAVEL PACK LIfaorble)
torage and Recovery EaSalinity Barrier FROM I TO I MATERIALtliferTest 1 oStonnwater Drainage petinieoal Technology InSubsidence Control I l it. , it
MG:othetmal(Closed Loop) :-Tracer 20.DRILLDiG LOG(attach additional sheets if aeeosarr)
I TO I DESCRIPT[ON!ationbardam.sanhodttaat.arateOmelet
"Geothermal(Headng(CooliagA 1t) (Other(explain under#Zi Remarks) FROM fa I O_� fa I clay a sand
4.Date Wells)Completed:I / 1,4?0�i Weli IDt 65 [t I,350 ft. I granR..
1 ft. t ft.
Se.Well Location:
M itha e.t f ft. I ft. :-:r. �- ; 1 ,
YeeilityyOwatr lame I .Facility IDc(if-applicable) I ft I fL i
s -- � it- 2 � AIIG 1 L: 2093
l�pow d 1 YOt,:I 1 1t PAS 28 7p I �+ It. I ft
Pays Address.City.end Zip i 75bo-5I- H�1(o$ 31.REMARIts Irw.`1.r>rfc,..itrrl I')r ^'R.^-,'.z•.2I!rtI±
yIACaLse,y (�er„esTy D1/4"tia:BOCII
County I Peinei Idcntifieation No.(PL1) •
5b.Latitude sad longitude is degrees/a:inuteslsecoads or decimal degrees: 1
(if well Sc)d,one latlioag is sufficient) 22.Certification:
35° Oki, rill N 083° 07. 7a?8 w /e40-44,;ff v.._ ci-s. 1 18 dG
I Signature ofCe:tifredWell Contractor
6.Is(are)the tvelks*eitnanent or OTe:mparaty
dy signing:ki s form.I hereby certify-that t uril(s)was tars)coamrtGed in accord
7.Is this a repair to an editing well: DYes or No with 15A CAC 02C.0/00 or 1S.4 YCBC 02C.0200 Stilt Coostraetion Smear*aad tl
f this ire repair, ill end ktwon'writ construction information eesgleir.the'taw=of tits copy ofhhis record has been prodded to the urll mom
repair wader All remark:section area the back of this fans. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or
B.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only I IFW-I is needed. Indicate TOTAL NUMBER of wells
drilled: f I SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 5o Cit.) 24a. For .A.H Shells: Submit this form within 30 days of completion of
Far aulltiple writs Cat all deptics ifd ffirrnt tlxarnplr-3@200'and 2Qa 1001 construction to the following:
10.Static water level below•top of casing: 1(0 (ft.) Division of Water Resources,Information Processing Unit,
!twofer love is above easbtg.ttse"=- I617 Mall Service Center,Raleigh,NC 27699-I 6I7
11.Borehole dtamerer. `Q (tin) 7.4b.For Infection Wells: In addition to sending the form to the addtras i
y � n� above.also submit one copy of this form within 30 days of completion of
1 �2.Well construction method: � . J 0.1 consuttction to the following:
(.e.auger,rotary,table,diteeetlpus5.ere.) l.J
t Division of Water Resources,Underground Injection Control Progra
FOR WATER SUPPLY/]WELLS ONLY: I 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Wm} 0 Method of test:✓ 1 2.Sc.For Water Suooh&Iniection Neils: In addition to sending the D
e addressees)'above. eisa submit one copy of this form within 30 th
I3b.Disinfection type:
rrSS Amount: Q i t I mecompletion of well construction to the county health department of the 1
I rl
tYGCre constructed.
\nisi Carolina Depar-.mtt af:m::onns.::1 Q_iEt`•-Disio.-.of t:_:.r�ou:ca R.-tired I-:
Form OW-1I I
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