GW1-2021-05925_Well Construction - GW1_20211025

CONSTRUCTION RECORD(G'9 1) For InteEM111 Use Only.
L Won Contractor hbrmatton:
14.�VATSRZONES
FROM TO 50CRWTIOPI
well ContmetorN e IL Q3 P
NC wcll Cwummor Certification Number 1S,OIUTSR tt—A—ffOk OR LIiVEti
Stephenson%Well Drilling, Inc. FROM T° nI IMIMMUS
n �S, It �l % In. S IDK al V C
COD1 nyN I&MURCASINGMT0B1NG
2.Well Construction Permits:: �� amum TO DUNaxFs TMCUMM n�ta, i6r
List all ifglfeabie wdl MVM=P rmlts(Le WC G=W,ftft yatf==eW
3.Well Use(check well use):
Water supply we . mom TO THICIOvMM- KATMOAL
pdn� Omimidipaimablic At AtG �•
Geothemrs[(Hcating/CoolingSuppiy) csidcntiai WatwSgpIy(single) fL fL -
IndoserialfCommercial DRoddential Water Supply(sbated) is cxouT
FffwRhm-e
rlr
111M To otATERrAL SHMACEMMrOMMEM&Aarourrr
NORxsupplyweII: M e.` fr e, W SQ Ib
ing IL it C f
Well: {�
Recharge [Grolmdwater Remu:dtion tR SANt1/GRAVSL PACK MO
Storage and Recovery [solinityBattier FROM Ta mA EMAETest QfStormaaoerDminageental Technology OSubsideaceControl mal(Closed Loop) DTI 20 Dfd LM I aG ad oaal ai"si
w ea6n Caolin Retttm Otber( laintmder#2i Rcmadcs) nast'2s>prloa �
tz r I
4.Date Well(s)Completed: 0► s- a� Welt M# ( n- a A
So.Well Location. gyp - o,,d mI fo.
Csre span. ?Q;►-jt LLC-
FaeiWyIOwwNmna FacilityIDa(ifappGeohle) m
4105 F..tr•►1v Lr, Oxfora a'1s65 Lo`t fL
Ph(y IcW Ad&=CiWj had 4 ft. �
County PaccelIdmti6oationNo(PIII} pICS
�
ili
5b.Latitude and longitnde in degreesiminttWseconds or decimal degrees:
(irweil field.one taring is nflidcnt) 22.Certification:
a t l —N ° 31 -��� W
6.1s{ara)ft we"(s) permanent or [Temporary Sig nw=ofUdisas wen Contractor Date
PVT By jWft d*fonM I baeby aerO drat floe u OV)mar(MV=Mvded 10 OcWd nee
7.Is thisa repair to as adsting wa. [Yes or mNo itwh ISANCAC 62C.0100 oriSANCRC 02C-WW IVeff Cmn*acdon Sraadn*and that e
Ifdris isarepair,fill ant Imotva weif tonrovdian infomtarioaand eipfafa thenarare ojthe wR ojihisrawdimshem piordded to dt nellumer.
repatr•mdder 021 r=wkrjwdm or on die back ofthirform. 23 Site dlegramt or addttlonal weR details:
&For GeoprobefDPT or Closed-Loop Geothermal Wells Laving the same You may use the back of this page to provide addidand well site details or well
CaaS coop,enly i GW I is needed. Iudicok TOTAL NUMBER ofwells dam-Yontuay also at�t additional pages ifn y.
drill..:,^ crmlyttrfer_INSi'8II_Cr!?O1ttS
9.Total well depth below land solU= a 5 (M) 24a.For All Wells: Submit this farm within 30 days of completion of well
Formaltipk we&fin off deplhsifiVerW(mmple-3e200'andd2@1005 araii to the following:
IIL Static water level below top of casing: 3 V (�) Division of Water Remnrres,Information Processing Unit,
ift wwr level Is above ewi»g,use+- 1617 MM Service Center,Ralel96,NC 2789-1617
1L Borehole diameter: 6 (ln.) 24h.Fgr Iniectioa Wells: la addition to seadiag the form to the address io 24a
ebo
12.Well construction method: /"�1 (�a`}"c.r�I eb v �of this farm within 30 days of completion of well
(La augtr,minty,whit;dnectptab,etc.)
Divisionof Water Resowus,Uadergrmud Wecdon Control Program,
FOR WATER SUPPLY VAffM ONLY 1636 Mail Sawn a Centel',Reidgb,NC 27694-1636
13a.Yield Om) 12, Method af ter mh Q. 24a For Water Simply 6t Tniectioa Welts: in addition to sending the form to
the addtess(es) above, also submit one cagy of this farm within 30 days of
13b.Disinfection type: h-r — Amok 1 b. Completion of well rnnstruuetioa to the county Leahh d of the cowrty
where constructed.
V.—nw-t Nw&cmaline Dcauftnew arEnvnonmmwouahty-Divis=efwaterRew=w Revised2-222016