GW1-2021-03321_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
I.Wefl Contractor Information:
'T ' E-A"6,n s a t1 1a:wATExzoNEs
Well Contractor Nathe FROM TO DESCRIP170N
aLkg � 3os ft. 3os fL
, 1
NC Well Contractor Certification Number 15.OUTER CASING for mpltitased wells OR LINER d Iicabte
Stephenson's Well Drilling, Inc. FROM To DIAMETER. THICIQVESS MATERAAi
rt. 112� It- �I in. S�� al v c
Company Name
��\\ 16.R4NER CASING OR TUBING( therms[eyed-loo
2.Well Construction Permit#: FROM To DL4MErER TmclavFss MATERIAL
List all applicable ivell construction permits f e.UIC,Couw.State.Variance,etc-) ft• f-- in.
3.Well Use(check well use): It. fL In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE TNICKNT.SS MATERIAL
Agricultural OMunicipal/Public IVIA ft, ft, im
Geothermal(Heating/Cooling Supply) oRcsidenti.1 Water Supply(single) fL is
industrial/Commercial DResidential Water Supply(shared)
1&GROUT .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Pion-Water Supply Well: ft. a ft e.n 0 n Lk Ir S l L Q f
Monitoring 011ccovery fL ft. C L• f�
Injection Well: he
ft. fL
Aquifer Recharge DGrnundwater Remediation
19:SAND/GRAVEL PACK rf applicable) -
Aquifer Storage and Recovery Dsalinity Barrier FROM TO I MATERIAL I EMPLACE6tENC METHOD
Aquifer Test OStormwater Drainage ft•
Experimental Technology OSubsidence Control ft. n
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Coolin Return) Other( lain under#21 Remarks) FROM TO DESCRIPTION color,audam smnrork m sv�ere
fL
4.Date Wells Completed:�-a S'�.� Well W# ft. ft-
Sa.Well Location: aQ ft. ft. r s`p��(� -Co,
Qre..cho n Pointe, LLC d-1 ft. 3`�S L
Facility/Owner Name Facility ID#(ifappliwbic) ft. ft.
ZQt 1`t ft. fL
Physical Address,City,and Zip ft• & t p
G ra tw�lle, I°��O��VN3%q`N 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
JUN
(if well field,one tat/long is sufficient) 22.Certification:
o W
r;ntafln prossing Unit
t
3S I� `E-1 N CA 3l S� W _ ®;°did SWozion
6.Is(are)the well(s) Permanent or OTemporary S Well Contractor V Date
By signing this form.(hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: DYes or-ONo ulth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fell out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform.
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 well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed: o
— - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 31 ` (R.} 24a. For All Wells: Subiit,this form within 30 days of completion of well
For mu1liple wells list all depths ifdrfferent(example-3Q200'and 1(a}I001 construction to the following
10.Static water level below top of casing. (ft.) Division of Water Resources,Information Processing Unit,
If water level is above rasing.use-+` 1617 Matz Service Center,Raleigh,NC 27699-1617
Pi '
11.Borehole diameter: (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this foam within 30 days of completion of well
12.Well construction method: if P' o r y
(Le.auger,rotary,cable,dimes pusb,etc.) construction to the foilowing
FOR WATER SUPPLY WELLS ONLY- Division of Water Resources,Underground Injection Control Program,
1636 Marl Ser¢vr'ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Q30"oks e, 24c.For Water Supply& (Infection Wells: In addition to sending the form to
the addtess(es) above, also I submit one copy of this form within 30 days of
13b.Disinfection type: Amount: —1 1b. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of-Environmental Ouality-Division of WaterResources Revised 2 22-2016