GW1--05383_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD (GW-12 For L reraal Use Only.
I.Well Coat:setor Inforrnatioa:
Russet Taylor
wen Coate xemc •
i u.WATER ZONES
' ! 70 DESCRIPTION
2187-A I 1/1 w 11Co
xc Weil Coataetor Cats ad Ntt:abes 10.3 1 4o8 Q-
{adden Brothers Wei( Drilling, Inc d q ! DIAMETER"'a'}oszaa or
Compaq Name i- ft. - ho. r
a a�_ L .Fti'NER CASING O&TUBING(pmtDcasi d•ubteeul
I.Weil Confirmation Permit SF: o 44441-9- /387 I I m I T I nuasE; ! r M,:Or 07 eppileable sell coraao cave pemits as.WC.:away.Stale✓erie r.etc) f 1 q4.1 rt. ! is ie. }
1pvc.
3.Well Use(check well use). ft. I tD m S TE E
Water Supply Wept 7.SCRIM" 8 a
Acieultural a• t TO 1 DIMrETER� 1 SLOTS= i cE 1 as
Mtmicipaiattciic r. fr. 1 Ia. faectizetudel
aIaenns/CoaIrag Supply) FResidea3al W ate:Supply(single) IInd 8 ... isr � � i
isuial/CO$ngCial `d-''?nc;:..e:�f Wa�¢Supply(soar i
Irrigation GRt)LT
Non-Witter Supply11 ROM TO �urr�tL�: at�t.r<ctnt r sttTBoA
Well:
,
11 iO 2 mamma 1 PLe�d
° g Mnccr cry ft.
faction WellItosh ;I--i_ j
uifc Rechacgc -
C�:adwzi.--. rv:ac: i'
�r 19.SA.�IGRA.VEL.PACK(irappCreablel
Storage area�`'R5' 8aiit3."y Baczic �o�t TO
sL�tERLu. i L�at6.t�►!L�'r>t�
gifts TlitExperitteestaMI Sta.��rax Draizagc ft. -
i Technology OSt:bsideace Coctsoi f:. r
;reot$C�il(Closed Leap) :..t` act 1D.BRIL.LIkG LOG fsmch edditioast sheets Yasusaar�?
Ctaothermtl(Heatia�lCooiiagiZra�t) €RtOt ce:cnlaia adc-2i iemarrs) FRaat TO/ t DESCRIPTION ceelor lvrssRr.wan np+asa man
! l 7 clay a sync
4.Date well(:)Completed: 8/l9 ja�� { •��: = I -jy h. l p z:.
Sit.Well Location: rt. ! r
Ri Hy Joe.,Mel-ten - r j •.'L.. /`
rd R ` � i SEPea
* h v -ae'liry Z)�tr.'ar-ezbiei
104 Old /ndp.l nos (\� /l Q Ft. ( 9 ?D2�
Physical Address..Ow.seed zip I I It
s 11 .J C,ouory 95 f 9. 9 9- 8973 , SU REML�= u
Coucry ?reel id=aft No.;PI.N1
Sb.La:ade and Saa;smde Ss:digrecsiaata.stesisecoads or decimal degrees: '
iifpeii .eld oec iaYtoab is rzfficeatl Z_Certification:
a J9. 358 N 083° PI.5!'4 w j ate. l 9 e •
6.Is(are)the well(S)i*erfaaneer or : ettiporal-t Si�ratu a oft ciSed Wei Caaz acm es
f
Sy-i grirg this jinn,f lien*are),oou)t►wars/was( r ri cw graRRed re
7.Is this a repair to asses ug well: DYes or No „'+i:154 3'GEC 22C.0100 or 11.4 NCBC 02C.0260 ZiaCaosnvrraso Seniors
trail @ e repair fl1 our!noun well mesa-.rction info:era:ion aegiicin:,:e.terry_of rirr copy Dial:?read beer.Preriefeci m ehe w&ewee.
ryofr wider tr31 meaner sPcrimr ar Ca the bac*ofrlrsfam J.Sire diagram of additional well details
S.For GeoprobdDPT or Closed-hoop Geothermal Wells cavine the st:.e You mar use the back of his page to provide additional wall site Ilea
eooaoi c ion only I GW-I Is needed. Indicate TOTAL NI.ilviBEP of well eoasavetioa dertaits You may also attach additional F if ttscwaty,
drilled: t
t
susk�ITT.u.INSTRUCTIONS
4.Total well depth below land surface:
'.
For.na/ttplr twits Tat ail depart ifdrffirr,rr iestmr+ie-3Q300'mzc Sir`:00? if`� 3n su r..lor.o For AI Wells: Suh=it:his for within 30 days of eaapish
cgr. f the foliiowinz
10.dratic water revel below top of easing. 00 i:c.: Uivsior.of water Resources,inforrttatioa Processing Vol
.:Twanarlroi x abow
eating.laa` i 617 Mail Semiee Center,Raleigh,NC 276994617
ti.EosaLole at¢aseter: Laflit ;:D.;or iniecdon\Veils: ;.a addisioe to reading$e 3brst to the edc
1A Well maatraeaari taerhod: \ abo.c,also scaraz one copy of this form wiYaaf 30 days of emepl-f
Cts mew.rosy,able.deem —w copse: a:::a ha fe ilo�rn
wash.etc:'
FOR wwTSR SUPPLY R'ELZ 5 ONLY: Dfrision of WCterResoarees,Underground Injealoe Control P
6
1636 Mail Service Center,Raleigh.NC Z709-1636
L3a.Yield(spas) 4o Method of rest Sic.For Warr. Sivayv&IaLeetiaa Welts In addtioa to seedin
LA ir ; die address(es) above. also sabn it one copy of this foan within
Lab.Distateetioa type: E Amour::: '. i Q GZr : coo:pledoa of well :gascuction to Me county health dspastutatt of
., t wcere eons-:ouni
Form CAW.; \a.�:.a.-o:aa.:7,17, i-n:afar.,yaaaa-.i Q:.ziiry-Di:=ras of V:s::r.oc.-c.s R.si