GW1-2021-00340_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW71) For Internal Use ODIy.
1.Well Contractor Information: _—�
�] �, {'� ^h 14.WATER ZONES
S��F« 1 T . -� e e.�
WellContractm-NaineFROM TO DESCRIPIIOn
R fL ,t
R V R.
NC Well Contractor Cenifiestioa Number 15.OUTER CASING for mulUcssed wells OR LINER d e
Stephenson's Well Drilling, Inc. mom TO DIAa1E1PR TRIL,NFSS MATE uAL
Company Name ft• R C I in. SDR 0-( w L
���r� 16.INNER CASING OR TUBING rural dosed-loon)
2.Well Construction Permit 9: FROM TO DrAMErea TmCHNIM I MATERIAL
List all applicable well mnmuctim permits(,.e UIC.Cmmo,,Smte.Variance.etc) R R in•
3.Well Use(check well use): R IL in.
Water supply Well: 17.SCREEN
FROM 70 DWMETER SLar SIZE TmCKPPSS MrER1A AL
0Agriculture) QMlmicipaVPublic R R >a
Grothermal(Hcating/Cooling Supply) .�311tsidcntial Water Supply(single) R (L
Industrial/Commcrcial DResidential Water Supply(shared) UL GROUT
hrigation FROM I TO I MATERIAL 11 EMFLACENINr METHOD&AAourcr
Non-Water Supply Wen: R- ad D• , �f,Q, q SV(h
Monitoring EIRconvay, R R
LEajjT=h
eB:
R R.
charge QGnmadwater Remothation 19.SAND/GRAVEL PACK e
orage and Recovery DSalmtty Barrier mom To MATERIAL kTdR,ACFhUKNI` ETDOD
s[ �Stormwa[er Drainage n. R
tal Technology Subsidence Control R R
l(Closed Loop) DTtacer 20.DRD.WNG LOG attach additional sheets if
l Hmb—Cooling Rerun) - Other(ex lain under ft2l Remarks) FROM To I DESOtIPDOla color.hw.es,mfll t Wata
1 O R. R 1
4.Date Well(s)Completed: \. ' " a1 Well tD0! R. R.
r
Sa.Well Location: �Q R ^15 rL rp' /� J-"" A 5 011
G -Qs-kuxrr \ 01I1�L �LL ft. '3VS-R
Faciliry/0w Name facility iD# fappiicabk) D• D•
bA11, v�.fof� �0 R R.
rhysieal Aa ,City,y,and zip R R.
CY(aoyr 11 21.REMARKS
County parcel Identification No.(FP!)
5b.Latitude and longitude in degrees/minuteslsecoods or decimal degrees:
(if well field,one laulung is sufficient) 22.Certification:
3�° 114/ t4I // N 1 ° 31 ' sS " WI - G al
6.Ware)the well(s7#/FPermanent or DTemporary Si Certil ed Well Co mr Date
l� By atgning drir form,I lrcreby certify that the aetl(s)Was(IvU raattruetei in accordance
7.Is this a repair loan existing wen: [DYes or,ONo wirh]JA NCAC 02C.0100 ar IJA NCAC 02C.020O WeB Cunstructiwt Standards and that a
/fthis is a repay,fill runt knona mil cmmructim information and explain the nature of the copy ofthd record has been provided to the cell owner.
repair under all rvtmhrsection oron the back ofthitforn.
23_Site diagram or additional well details:
8.For CeoprobdDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction
y 1 GWA is needed. Indicate TOTAL NUMBER of wells construction details. You my also attach additional pages if necessary,
drilled' , SUBMITTAL MSfRUCITONS
r-� n
9.Total well depth below land surface: O J I( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdffimmt(eemple-3@200'and 2@Jd construction to the following:
10.Static water level below cop of easing: 3 C (R) Division of Water Resources,Information Processing Unit,
If,wter level is above rasing.use-+- 1617 MaB Service Center,Raleigh,NC 276994617
11.Borehole diameter.�_010 241L For Infection Wens In addition to sending the form to the address in 24a
12.Well construction method: Nit- �,0 I (�� above, also submit we copy of this form within 30 days of completion of well
(La auger,romry,able,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4- Method of tat: r' 24.For Water Smmly&Injection Well: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Dlshafection type: ki T ♦-1 Amomt f�
II completion of wen construction to the county health department of the county
where constmeted
Form GW-1 North Carolina Department ofFavanu m and Oualav-Division of water Resources Revised 2-22-2016