GW1-2021-01697_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only. - - - --
1.Well Contractor Information: I
J 14.WATERZONFS
Well Contractor Name �•� 131 TO DESCRIPTIONrf, ft. 0 It. i
�`��a �SG `Y 1� s 3��-
NC Well Contractor Certification Number �i g 24
B 15.OUTER CASING for multi-cased wells OR LINER rf IIcable
Stephenson's Well Drilling, IncA�R �\�gv�1t FROM To DIADD?1F1t THICrtavEss MATERIAL
Company Name 3 `pQCI Q,�,Q(\ O ft. 113,J R. C l� in-. IS al B S6 16.C4NER CASING OR T(JBINGG(eothermai dosedaoo
2.Well Construction Permit#. 4 FROM TO DIAMETER TH1006SS MATERIAL
List all applicable well construction permits flA I1fC.Counts State,Variance efc) AIIAIt fL in'
3.Well Use(check well use): n• fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSUM THICIMMSS MATERIAL
i Agricultural 0 rcrpal/Public ft. R, in
Geotbermal(Heating/Cooling Supply) Residential Water Supply(single) R %
industrial/Commercial DResidential Water Supply(shared) I&GROUT
-11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AhiouNT
Non-Water Supply Well: ft. IL Q n 0 U So q
Monitoring DRecovery ft & C
Injection Well:
k. ft.
Aquifer Recharge DGroundwater Remediation
19:SAND/GRAVEL PACK da licable
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL I EMPLACEMENT hMMOD
Aquifer Test DStormwater Drainage f-
Experimental Technology Dsubsidence Control ft. tt
Geothermal(Closed Loop) DTra= 20.DRU:i.ING LOG attach additional sheets if n
Geothermal(Heating/Cooling Return) — Other(explain under#21 Remadrs) FROMI TO DESCRIPTION color,hardness,sort oek In sirs,etr-
4.Date Wetl(s)Completed: — —� Well RW n• ft ! 9 C
Sa.Well Location: D' �, r 44 -r011
Qyro,shalA Q�►ht� ��.c �� ft: s6s t�
Facility/OwnerNaAme Facility ID11#(ifappticablc) ft. ft.
Ll& S lT S Aw y I�.W �-h, ®XfC)t-fR a156 j ft. fL
Physical Address,City,and Zip p[� i?• ft.
Qr ro v*,Ile, I g30op "p, fn sr 21_REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
14' 3'D\" N -1 ° 3 I �� W
6 h(are)the wellwpPerrnanent or Temporary SignWrc drCcrtificll Well Contractod Date
By signing this form.I hereby certify that Ore vvil(s)runs(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or-ONo ulth ISA NCAC 02C.0100 or 1SA NCAC 01C.0200 Weft Construction Standards and that a
if this is a repair,fell out known well construction information and explain the nature of the copy ofthis record has been provided to the ivell owner.
repair under#21 remarks section or on the 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: Z
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperenI(example-3@200'mid 2@1MI construction to the following
10.Static water level below top of casing: 3® (M) Division of Water Resources,Information Processing Unit,
Ifrwterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Q .} above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 C i�01�f y construction to the following.
(i.e auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Ser�vfce Center,Raleigh,NC 27699-1636
t;13a.Yield(gpm) Method of tes _ A 24c.For Water Sunnly& IIniection'Wells: In addition to sending the form to
-{ u the add=(es) above, also Isubmit one copy of this form within 30 days of
13b.Disinfection type: 1 !1 Amount: 2` ,b.f• completion of well construction to the county health department of the county
where constructed.
I
Perm r:W-i North Carolina Denartment of Environmental Oualitv-Division of Water Resources i Revised 2-22-2016