GW1-2021-01772_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
L Well Contractor Information:
-T 14.WATERZONW
well Contractor Name FROM TO DESCRIMON1
�oZ�otia � 31 ft' 3!4 1 � CT M
ft. %
NC%cell Contractor Certification Number 15 OUTER CASIIYG ffor multi-cased weAs OR LINER r[ Utable
Stephenson's Well Drilling, Inc. EOM DIA1rWM
ft. / in. sop,a c,
Company Name
3a�t� �.IxNSR CA51NG OR TUBING dmeddo
2.Well Construction Permit#: 6� Pff:
TO D�ET� Tin MA RU
List all applicable well construction permits#.e.UIC.Cowin:State Varian=etchIG W
3.Well Use(check well use): m In
Water Supply Well: 1FROM To I DIAMETER L SLAT Sig I TfnCi NTSS MATERIAL
Agricultural [municipal/Public n" n In
Geothermal(Heating/Cooling Supply) ,01k sidetitial Water Supply(single) ft, ft. In
IndustriaUCommcrcial [Residential Water Supply(shared) I&GROUT
1-11rrization FROM To MATERML EMPLACEbnfffr ME'I80D&AMOtAVT
Non-Water Supply Well: Q ft- @, `Q^;*e POVEag so lb bwv
Monitoring DRecovery ft. ft. C�•
Injection Well: ft.
Aquifer Recharge [Grmmdwater Remediation
19 SAND/GRAVEL PACK a 1lcable
Aquifer Storage and Recovery DsalinityBarrier FROM I TO MATERUL MWPLACMIMMai"MI)
Aquifer Test [StormwaterMainage A4 ft. EG
xperimental Technology OSubsidence Control % ft-
Geothermal(Closed Loop) [Tracer 2U.DRILLING LOG attach additional sheets if
RGeothermal(Heating/Cooling Return) r30ther(cxplainundcr#21 Remarks) FROM TO I DFSCRW IOR color,tmranmm sov orx fte,grain am dr
ft. ft.
4.Date Well(s)Completed: -a.3`2�1 Wet!ID# I ft' 3 5— ft' S4 C A,
5a.Well Location: 39 ITI 16rowh sort. f 0 I
Q5VQ.s1\o.w, lOZ 3"AS"
Facility/Owner Name Facility M#(ifappiieable) ft M
4S"711 /l.rkl V;w Lni 1.0f -1a oxford► ft. fL
Physical Address,City,and Zip
2LREMARKS
County Parcel Ideati6cnionNo.(PIN)
Unit
5b.Latitude and longitude in degreesIn inubmtseconds or decimal degrees: (tpn PfOCeSSIng
(ifwell field,one lat/long is sufficient) 22.Certification: p�J By
30l-II -AI// N. 22"
31/ ��/ W I , `D,3- O
6.Is(are)the wellspPermanent or []Temporary SigaiturbWCerfifilbd Well Contracibr Date
si this orjm I carat that the nell(s)was(were)constructed in accordance Br i 8 f �bY h'
7.Is this a repair to an existing well: [Yes or.42fNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifdtis is a repair,fdl out known well constriction information and explain the nature of dhe cM,ofthis record has been provided to the well miner.
-pair under#21 remarks section or on the back ofthisform
23.Site diagram or additional well details:
&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.
dulled: 1' P �SUBMTITAL INSTRUCTIONS
9.Total well depth below Indsurface. 34J (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerrrrl(eromple-3Q200'and 1Q1M construction to the following:
10.Static water level below top of casing: 3® (S.) Division of Water Resources,Information Processing Unit,
If ivater level is above casing.use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (n.) 24b.For Iniection Well=. In addition to sending the form to the address in 24a
12.Well construction method: Air Imtltary abovt;also submit one copy of this form within 30 days of completion of well
(ire.auger,mtary,cable,direct push,ctc.) construction to the following'.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-1636
13a.Yield(gpm)�h _ Method of test: Qsoq 24c.For Water Sunn v&Infection Wells: In addition to sending the form to
1 the addless(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: T I� Amount: 116,, completion of well construction to the county health department of the county
where constructed
NnAh r muna Drn,Ampm nrEnvimnmemai noelity-Division of Water Resources Revised 2-22 2016