GW1-2021-01693_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
ID
S e,nf 14:wATERZONFS i.
Well Contractor Name FROM TO DESCRtPTIONI
Pr 2 9 2p11 3 10 QT
NumberNC Well Contractor Certification PR ���<
Stephenson's Well Drilling, Inc. P3«apt d%0A FRO"'$R TO farmDwmm ox� IiMA
10
Company Name (:3 ft. ft. in- I S pR Al I V C
3�� I&INNER CAMG OR TWING(eothermat dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER TIHCi MESS MATERIAL
List all applicable will construction permits r e UiC County,.Stag Variance,era) A11A 'L In.
3.Well Use(check well use): & fL ra
Water Supply Well
17.SCREEN _
FROM TO DIAMETER SLOT SITE THICKN M MATERIAL
Agricultural DMunicipat/Public AIIA fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
rt. ft,
Industrial/Commercial QiResidential Water Supply(shared) i8.GROUT
PIrri-gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft � IL Q-`fioAt Q w- 11 SO b r
Monitoring Recovery & & C f
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation 19:SANDlGRAVEL PACK da licabtel
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage AIIAft• %
Experimental Technology Dsubsidence Control ft. it:
Geothermal(Closed Loop) DTracer 20.1) LOG attach additional sheets Kn
Geothermal(Heating/Cooling Return) - Other(explain under#21 Remarks) FROM TO DFSCRm710Nr color,bnrdnm soRtrock tye,croin saa etc
fl. & 101
4.Date Well(s)Completed: Lk— (�.� Well ID# ft. e`Q ft. R CIO A
Sa.Well Location: , 0 f' !
C3cQsho.rr IO•Irdg- LIS. 0 ft. 31A5 ft- ; K
Facility/Owner Name Facility 1D#(ifapplicablc) R• fL
/tS, RSM&N�11-ew Lo.t c, Lot Q6 Oxford\ ��5�5 fL
A
Physical Address,City,and Zip O• R•
Q3T-0.tv',IIe, 1°�300a°���a�a 21.RElNARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22-Certification:
N 21 31 Lk-A: W
6.Is(are)the well(s)MiPermanent or Temporary S Ccrmfi dd Wcll Contactor Date
By signing this form.I hereby certify that the weU(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or.dNo with ISA NCAC 01C.0100 or ISA NCAC 02C.0100 Weft Construction Standards and that a
if this is a repair,fdl out known well construction information and explain the nature of the cep"ofthis record has been provided to the ivell owner.
repair under#21 remarks section or on ttre back of thisform.
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.
drilled. a- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3`-�✓ (ff) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdrperant(erample-3Q200'and?QI00) construction to the following:
6
10.Static water level below top of casing: Division of Water Resources,information Processing Unit,
ljrvaterlevel is above casing.use_+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (m.) 24b.For Injection Wens: in addition to sending the form to the address in 24a
12.Well construction method: N1 C E(ft Oaf v above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY(
(WELLS ONLY: 1636 Mail Se E lce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: C1=0.���, 24c.For Water SunDW&Iniection Wells: In addition to sending the form to
_ 2 I� the addtess(es) above, also submit bne copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. 9
Fnrm[:W-1 North Carolina DerlaAmeM of Envirrinmental(hlality-tlivicinn of Water Reanui q I R—i—d 7-77-7n1 r,