GW1--08075_Well Construction - GW1_20231215

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WELL CONSTRUCTION RECORD (GW 1) I p I
1 e Inteiaal Use Oaly.
I.Well Contractor Information: I 1,
Russell Taylor ' 14,Si'ATRRzc1FI:S
WWI CanaetorN me • i FROM I TO i 1 I DESCRIPTION
2187-A `8i E` l Si., I 1133-138
NC Well Coairactor Contfnttion Number {dam f" en0l0 ft. I.r l-o14P
15.OUTER CAMG(for comet asedw'ells)ORLI=Of
Hedden Brothers Well Drilling, m G ; FROM I TO I DIAMETER 1 ?lucre, minim •
Company Name
fr. I • ft. In. I
I I6.I11TISIt CASING ORTURINGitteat6amaidaedl000l- •
Z.Well Construction Perron;: (20.5 -,489?-9- is' I FROM I TO I DIAMETER I TRICSORISS Mallittat.
Lin all op/Raz l<well evestruedcn permits a.e.UIC County,State,Variance,etc) I. 0 ft I (OCO 6 lm t QVC•
3.Well Use(sheds well cue): ` `
l�io i loB [� m I .188 STEEL
Water supply well: 1 I7:St lEElti
• FROM I TO I DIAMETER SLOTS= TIIICXESS [ NATLa1AL
�MttnicipaTalthiic 1 ft. ft. ie. 1
Geoff aleating/Cool ng Supply) ERestdential Water Supply(siagie) I fa;I in.
IndusaialiCommazial DResider al Water Supply(shared) 18.GROLT! 1
Irtiaitioo FROM ! TO I MATERIAL 1 EMPLA TDIETCatt ollaAMOSI
Non-Water Supply Well- j 0 f= ( m 0• ( >........ ( clued
Monitoring M eLy ;I ft. i ft.
faction?Veil; fr ( ft. I -
tliferRetharge D rrottadwzxrRctaediztion
19.UM/GRAVEL PACK of aaplieab1e
• Storage and Recovery Salinity Barrie I FROM I To I MATERIAL ` FsfrLACEMM'atarxoD
Gifu Test DStorotwate rDrainage f ft. fr. II
Experitnental Technology 0Subsidence Control (i ft. I I I --
Geothermal(QtlsedLoop) DTracer • 2t1,DRILLING LOG fattaeb additional shiest'nceesos9
0 D6t�t
Geothermal(HestjngitooliagRemo ex) flother( plainundo;21Remarks) . PEE Et. ,it day a sano mine ei tmlor.earanm.wun.dctetwmte test
4.Date Wells)Coinplsted: II I/etata3 Wells # SR tc• 460,O. granite
Sa.Wall Location. r ' ..
. d Organ - - -, , �.. ���Z...,:�,�r�. 4
t
.5 iSi me 1
FtttdHrylOwaa�T Facility ID�(i:apgGearriej ft. )nL?
Rc toinawT 3yIvo ,?e799 - !rc. 2 (ft. `v ---
P sal Address,city.and Zip
71R51-IGS- •1�7�i.S 21.REMARKS law t..', ^ ti •
City Parcel identification No.(FIN) 1
5b.Latitude and Longitude is degrees/taiautes/seconds or decimal degrees:
lifwall 5eid,ono Moog is stlites:n:1 22.Certffiratian;
id! ,�a.194 ri 083° ID•2017,_..6t4.4..r1„;_gpl JQ,t.
6.Is(are)the well(s) Permanent or O'iemporary
Sigatum ofCenifred Well Contact;:
3y signing:kilt form.i scenic•.•err*that t scarce was there)cameraae+d in avow
7.Is this a repair to act existing well: DYes or pie nick15d NC4C J3C.0100 or ISA:t 4C 02C.0200 Weil Coastryetfeet Standards gad
If tliir lr a rttjra•.fill out know:well eotcctructiaa irrfossit tiaa at iein the cotter=oftnr ropy ofvris recant it=been provided to the icell otcnen
repair ctderi I remark secrden or ate the boat:aphis farm- - 23.Site diagram or additional well details:
8.For Geoprobe&DPT or Closed-Loop Geothermal Wells having the saute You may test the back of this past to provide additional well site desalts of
sonsolation,only I FAT is needed Indicate TOTAL NUMBER of wells constatet oa details.You may also attach additional pages if necessary.drilled: 11 SUBMITTAL INSTRUCTIONS '
4.Towel well depth below land surface: Of 5O (174 24a- For An Wells: Submit this fo:3t within 30 days of completion.01
Farowinpie liarthe all depth;refill-treat(exerplr-3Q300'end�+2@/0O'} coasrsietoa to the following
10.Static water hoes below top of casing; �) (fa) Division of Water Resources,Information Processing Unit,
lftcgeer level it sham easierg.are--,1"
I617 Man Ser it a Center.Raleigh,NC 37699.1617
II.Borehole dlamerer. (fa) 24b.For Iaie Ition Wens:- In addition to sending the fora m the address.
to.weft coasti-aWiaa mcrhuaa atTt.
11.c.r1C 0, -k above,also sobs*:one copy of this form'Meal 30 dere of e:ompleeten a
r mosstso:ie.to'itha fallowing: -
(t a-=gcr Mari.table.direct putts.eta] I
Ditiisior.of Water Resources,Underground Injection Control Proses
FOR WATER SUPPLY WELLS ONLY: 1 1636 Mail Service Center,Raleigh,NC 27Fr99-Iti3ti
nn � �� ^� r
I3a.Yieid(gpm) 0l0 Method of test LYti+.%tu t �.c•For Water suooiv&Inlcettan Welt% In addition to readig thc•f
ffSS 1 the addresses) above. nISo submit one copy of this form within 30 d
13b.Disinfection tvpen r ri ;�moanr. [Q 1 eompiedoa of Well eonsmuction to Me cotmty health department of't5e
where eensltiett d.
Form OW-i Nola Carolina Donor-cm of � a�i.�_
5-, n . ii 'D - .-.- -. I of t:_.cr Raou:e o Rc,ised3,
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