GW1-2021-07405_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractorinformation::
WATERZONES
Well
rContractor�N me ae FROM To DESCREMON
c�C�olo'. r\ �� D• .SrIC4 ff' vZ'I/1
@. (L i'
NC Well Contractor Certification Number
15.OUTER CASING for multi=cased weQs OR LINER(If liable
Stephenson's Well Drilling, Inc. FROM I To I DIAMETER I TIDCKAFM MATERIAL.
Company Name f t. 3q t. (�.y in. S p R a,\ V C
�� �� 16.INNER CASING OR TUBING thermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMUM TMCKNESS I MATERIAL.
List all applicable spell construction permits r.e U/C.Counv.Stag Variance,eta) o' is
3.Well Use(check well use): ff' fL in.
Water Supply Well: 17.SCREEN
FROM TO MANEMR SLOTSITE TMCKNTM MATERIAL
Agricultural MunicipaMblic It, ft. in.
Geothermal(Heating/Cooling Supply) oRcsidcntial Water Supply(single)
R 2
lndustrial/Commcrcial DResidential Water Supply(shared) .IS.GROUT
.'11rrigation FROM To MATERIAL EMPLACEDUM METHOD&AM
timrr
Non-Water Supply well: 01 SO lb b
" Monitoring DRecovcry & tt
Injection Well:
ff. ff.
Aquifer Recharge DGroundwater Remediation
t9:SAND/GRAVEL PACK applicable)
Aquifer Storage and Recovery QI$alinity Barrier FROM TO MATERIAL I EWI ACEM Mani ROD
Aquifer Test QlStornwater Drainage ft• IL
Experimental Technology OSnbsidence Control ff. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCR1 MOM(color,hardnem,soMroek skm ctr-.
tt. `10 JOl4.Date Wells)Completed: -3 X Well ID# Qff•Sa.Well Location: S ,j 1Rmk\ v e.r� e. pis 5 ft... c
Facility/Owner Name Facility ID#(ifappficablc) it• EL
354 WY q6 S 0xfrA N, al565
Physical Address,City,and Zip ff• ff•
�'rr anv;lle. I�a°�oo al 6�s6 21 REMARKS
County Parcel Identification No.(PIN) 1111
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/tong is sufficient) 22.Certification: QvP J
N --V%° 34/ S-0-\1/ W
6.Is(are)the well(s)'Permanent or OTemporary SigAtiacVdctifi&I Well contracta Date
By si ring this form.I hereby certify that the nell(s)wns(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or-dNo xith 11A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
lfthis is a repair,fdl out known well construction information and explain die nature of the copi,ofthis record has been provided to the cell owner.
repair under#21 retnarkr section or on die back of thisform
23.Site diagram or addltional well details:
8.For GeoprobeMPT 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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
dulled 1 c C SIMMM—AL INSTRUCTIONS
9.Total well depth below land surface: �y✓ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtiff—t(example-3@200'and 2@ioo) construction to the following:'
10.Statie water level below top of casing. 3® UP Division of Water Resources,Information Processing Unit,
Ifivater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24&For Infection Wells: In addition to sending the form to the address in 24a
pp
12.Well construction method: �G�o.r above,also submit one copy'of this form within 30 days of completion of well
1-1 I C V
(Le.auger,rotary,cable,dir push,etc.) construction to the following
ect
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control Program,
I 1636 Matz Set vice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /� Method of test: 24Q For Water Supply&Infection Wells: In addition to sending the form to
the address(es) abotte, also I submit one 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.
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Form GW-1 North Carolina DepaAmeat of Environmental Ouality-Division of Water Resources Revised 2-22-2016