GW1--05913_Well Construction - GW1_20230918

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RIM
. WELL CONSTRUCTION RECORD (GW-1) For Interim'Use Only.
1.Well Contractor Information: k j
It I
Russell Taylor 14.WATER ZONES
Well Contractor Nam( FROM TO I I DESCRUFr1ON
2187-A I Igo? ft: 19 1
•NC well Contra: e:43 fc. 0?081 FL •
tar Certification Number I IS.OUTER CASING(for multhcased webs)CRLIINER(tratsgtiedle) •
Madden Brothers Well Drilling, Inc I FROM TO r DIAMETER THICIC(ESS MATERIAL
ft. ' 'fr. In.
Company Name n/� 1I 16.DINER CilSING DR aa)TUBING(geothermal cleseddo •
1.Well Construction Permit at: 090 Ir�iO—P I FROM t TO DIAMEFER TRIIIDDIESS MATERIAL
List all applicable well consituctlan pa aft (La UIC.Cetatty,State.Yeriance,eta) I. 0 n I 1 I C) ' /„ 1°' PVC
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3.well Use(check well use): .119 f:: I 0 1 fti to •/88 5 TEE L
Water Supply Well: 17.SCREEN
• PROM I TO DIAMETER SLOTSIZE TRIMNESS MATERIAL
Ageit:utturat DMaaicipal/Public ie. R. I ia.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) g, ft.II in.
Industsial/Commeteial D,, ,ential Water Supply(stated) ,
"�"� uPp y 1&GROLrf t 1
Irritation • FROM I TO I 1 I MATERIAL I EDMPL„temr 11TSIErHOD&AsioltX
Non-Water Supply Well: 0 ft zo 1 R- I ser=rx I ournaed
Monitoring rjBeeovery ft. rt. I
ection Well:
Aquifer Recharge QGroundwatcr Remediation fa I
I9.SAND/GRAVEL PACK(If eneueable)
' Storage and Recovery Salinity Barrier PROM To MATERIAL I PAIPLAGEMEITSIE ROD
Aquifer Test DStonnwaterDrainage ft. ft.
Experimental Technology 0Subsidence Control I fr. I m I
Geothermal(Closed Loop) DTTrdoer so.DRII LDtG LOG(attach additional sheets If neemsers1
Geothermal(H CoolingRetum) r lOther(explain under#21 Remarks) FROM I To I DESORMPTION teeter hardness.mutreee wee.erate Ifta.ere.(
0 R. I I 111 I day d sand
4.Date Well(s)Completed: 8/I55 Mtn 3 Well 11?# i l 1 I ft' 18 n- matte
• So.Well Location: i rt' I` fL i dp ..
Fin Ht nr.,5a1CC I ft. I f ft. I C b: +✓�.� (! R ,_[
Pacilfty/OwaerNam c Facility ID_(if applicable) 1 fG I 1, I (+r P y
108 t ,1 eray9itd Rd. OHO/ od87(AS 4 `` , ( J` Y 2023
Physical Address.Coy sad I n I t I Ifh`J.ir, :;•^il Pr,rr.;,•I.A;., l r., x.
Migia1.) Cnwsry 11478551R58 21.REMARKS yet:,:,�,,(.
County Parcel Identification No.(PLC} i •
51r.Latitude and Iorsgitatie in degree Jmiautes/seconds or decimal degrees: 1 ,
(if well Bold,one lit/long is sufficient) VI.Certification: !. •
.35° 00. 145 N 083° 45.411 W 8 17
s
6.Is(are)the well(s) Pertaanent or OTemporary SigtaaucofCrnificd Well Contractor
By signing this form,Ili hereby certify that t nr11(s!was Mrrr)caastrnted br match
7.1s this a repair to an existing well: DYes or NVo nith Mil)CAC OPC.O100 or 15A(CAC 03C.0200 Well Canrarredan Standards and to
/f this it a rrpair frll out Mann roll construction Informattan erplaim the nature of tint copy grab record has beer:provided to the im:1 otnrer.
repair:tadte C21 remarks radon area the back of this fann.
23.Site diagram or additional well details.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or
construction,only 1 OW-I is needed. Indicate TOTAL NUMBER of~cells construction details. You may also attach additional pages if aecetssty.
drilled: I SUBMITTAL 2NSTRUCTIONS•
9.Total wen depth below land surface: Sw (ft) 24a. For All Wells: Submit this form within 30 days.of completion of•
For multiple ttells lint all depths.it-different trsamplr-3ta�200'and 2 f IOO'} construction to the followinc
19.Static water level below top of casing: 80 (ft.) Division a Water Resourcess,Information Processing Unit,
ifwatarlaud it a.'Ie eerbrr.use 1" 1617 41at1 Service Center.RaIetis,NC 176994617
11.Borehole diameter. k.9 (Da) 24b.For Infection Neils. in addition to sending the form to the address in
j� tiL�` above,also submit one copy of this form within 30 cloys of completion of
12.Well construction method: 4d—` f�t tit 11�.+�jU construction to the feliowiae_
(is auger.rotary,cable.direst push,etc)
Division of Water Resources,Underground Injection Control ProvenFOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service(eater,Raleigh,NC 27699-1636
I3a.Yleld(gpw) 3 1Iethad of test EiGIA 34c.For Water Su &Infection Went: In addition to sending the for
i + the addresses) above. also submit one copy of this form within 30 day
13b.Disinfection type: '1S 1 t ,Amount: (le D� I completion of well(construction to the county health department of the cc
1. where constructed.
Form OW-I North Carolina Depritecmt ofEn immca:ntel Q_iixivsr.-Dio of I t'accr Rzources Revised2•?1
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