GW1-2021-01773_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only. ! -
1.Well Contractor Information:
�e.l \CQ.y 1 . S�Q�e.Y�fp11 14.WATERZONES . .
ES
Well Contractor FROM TO D CRIPTION
ame 30
GOA G`Vl F\ ft. fL
NC Well Contractor Certification Number
25.OUTER CASING or lnuld-cased wells OR LINER rf licable
Stephenson's Well Drilling, Inc. FROM To DIOWM THIC[QIFSS MATERIAL
® ft. --� ft. 1 in. SpR
Company Name l` Qr I&H%14EER CASING OR TUBING( thermal dosed400
2.Well Construction Permit#: 3a -\`cs FROM TO DIAMETER TMCKNM I MATERIAL
List all applicable well constructionpermits fl.e.UiC.Count);State-Variance,etc) ft• ft. in.
AII3.Well Use(check well use): ft' ft 1II
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITE TMCi NTM MATERIAL
Agricultural E)Municipal/Public ft. ft. 1 in.
Geothermal(FIcating/Cooling Supply) .Residential Water Supply(single) 0 M fL in.
Industrial/Commcrcial DResidential Water Supply(shared)
I&GROUT
FbIrripation FROM TO MATERIAL EMN ACEM W17 METHOD&AbIODNT
Non-Water Supply Well: ft' ft Q 0nk rjU r
Monitoring DRccovery ft. fL C .
Injection Well:
n fr.
Aquifer Recharge DGroundvmterRernediation
19:SAND/GRAVEL PACK rif livable
Aquifer Storage and Recovery OSalinityBarrier FROM TO MATERIAL E LACEM 'rh* TROD
Aquifer Test oStormwater Drainage ft• ft-
Experimental Technology OStlbsidenee Control ft. ft
Geothermal(Closed Loop) DTracer 20.DRII.LING LOG attach additional sheets if n
Geothermal Heating(Cooling Return) EtOther(explain under#21 Remarks) FROM TO DESCRTMON color,bmdnm,soWrartt ==etc.
ft. fL
4.Date Well(s)Completed: — ��a' Well ID# ft•
Sa.Well Location: .az r w m $'o' S0•1
Cyce.SkN,, pczin`\e., LLC.. o��fr. 3�sft. oc
Facciility/OwnerNamc Facility ID fL O(ifapplicable) ft
Lk 1-S hxkl%u Y`/icw Lore, List Cz°\ ufw& x1 rcx ff. ft.
Physical Addrew.City,and Zip p ry ft. ft• A t'N
y l 1 `3odd��1�l t, 2L REMARKS
rQ^^V 'L rrnatior,
County Parcel Identification No.(PIN) �rOCQ
ecdon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2L Certification:
3ro° 114' LiQ f N _ ��� 31/ �1u W _
Ir
6.Is(are)the well(s) Permanent or Temporary Si t ed Well Contrac r Date
9VV By signing this form.I hereby certify that the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: [3Yes orloNo sttth ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fill out known well construction information and explain the nature ofthe Cary ofthis record has been provided to the ivell 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, y 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled. I. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 a s- (R) 24a. For All Wells: Submit,this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2 100) construction to the following.,
10.Static water level below top of casing. 3Q UP Division of Water Resources,Information Processing Unit,
Iftvater level is above casing use-+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (la.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
AA
12.Well construction method: l t' 1 RO 0.r�I above,also submit one copy of this form within 30 days of completion of well
1'C construction to the following:
(Le.auger,rotary,cable,dirt push,etc.)
Division of Water Reso bees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se ce Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SDDDIv&Iniection Wells: In addition t0 sending the form to
1 the address(es) above also I submit bae copy of this form within 30 days of
13b.Disinfection type: Amount: Ib. completion of well construction to the county health department of the county
where constructed.
P.—t:W-1 North ramlura Denartmerd of Envimnmenml Onality-Division of Water Reamirccs Revised 7-22-701 A