GW1-2021-07407_Well Construction - GW1_20210921 (3)

WELL CONSTRUCTION RECORD(GW4) For lntl;rnal Use Only. --,----
1.Well Contractor Information: ®rl
�� 1 k\T\ 14. A7'SRZONES
Well Contractor Na6e TO DESCRIPiTOrV
S eaS, ft rL
rL
NC lt Contractor Canification Number s "'�T fo � rU u
StePhensons Well Drilling,, Inc. FRMO Dm
ft. sir S v C
CompanyNaroe Q I&INNER ORITIBIIYG aidose"
2.Well Construction Permit#: O�® To ntAMEretz r�c[aysss MATFW
List all applicable well conshrtedon permits(i e,t1IC.GwWo'.sw"ywianm etc) A11A % R I tn.
3.Well Use(checkwell use): ft. it: 14L
Water supply well: 11 SCREEN
FROM TO DIAM M SLOTSTE TinCKNIMS MAT e7nAL
Agricultural E)Municipal/Public n: ft. In
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R % j in.
Industrial/Commercial DResidcxttial Water Supply(shared)
18.GROUT
4AIrrization FROM TO MATERIAL 001 ACEMENTMETHOD&AMOUNT
Lion-Water Supply Well: s f
Monitoring ORcoovery ft. IL
injection Well: C' s
it &
Aquifer Recharge DGroundwaterRemediation
19.SAND/GRAVEL PACK rf lleable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL 00%ACVVWT METHOD
Aquifer Test OStotmwater Drainage D• n
Experimental Technology Oftliside nce Control & R
RGeothermal(Closed Loop) QlTtae 20.DRILLIIYC LOG attach adeo�l tireets K
Geothermal(Heatin Cooling Return) 00thcr(cxplain under#21 Remarks) mom T O DffiCRiP00N eabr soivraek Sim
p �-�� WlDI4.Date Well(s)Completed:
Q 0"
Ss.Well Location; fi' S- H: rown 1
5Qs1_ owe_� Lrc"j� im �omer LLc, S �� 30R o
Facility/Owner Name T FacilityM#(ifWU=btc) H• ft.
40aA Ahhlrt/L►%, S+e-m lkotke r;rle, Wcod-r R
Physical Address,Cily,and Zip
GI'o`nv;I�e. (�°�$d�,41I S.3 s-� 21REnaARxs
County Parcel IdetuificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(tfwell field,one tat/long is sufficient) 2L Certification:
N ��� 4�.' Ill W _
6.15(art)the weg(s ermanlat or [:)Temporary S ofC=drzcd well Co r Date
-
By By signing this form,t hereby terrify that dw ise(s)coos(were)cons Wed in accotdmtce
7.Is this a repair to an existing well: [3Yes or ONO nwh ISA NCACO2C.0100 or ISA NCAC 02C AM itrell ConsvuWan Standards and r/tat a
i'&&is a repair,fdl out hnoam ue0conruuctian itfwmadan and explain Aenature ofthe cM,offt record has been provided to Metaell owner.
repair under#21 remarkssedion or on die back ofthisform
23.Site diagram or additional well details-.
9.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW 1 is needed. Indicate TOTAL NUMBER of wells construction dells. Youmay also attach additional pages if necessary.
dnHcd' ' i t SUBMPITAL INSTRUCTION$
9.Total well depth below land surtltee: T 5-O (A) 24a. For All Wells: Submit this font within 30 days of complexion of well
Formrdtiple wells list all depths ifddrarent(example-3@200'and 1@I009 construction to the following:
10.Static water level below top of easing: (R) Division of Water Resources,Information Processing Unit,
Ificaterlevd is about eosin&use-+- 16I7 Mail Service'Cenber,Raleigh,NC 27699-1617
il.Borehole diameter: Cm-) 246.For jRjeejjM WeUr, lnladdition to sending the form to the address in 24a
^ above.,also submit one copy of this form within 30 days of completion of well
( e.Well construction cable, method: I t' f�Q I t7`f V construction to the fbllowing:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �_ Method of testy�G�(�1 _ 24c.For Water Supply&Injection Wells: In addition to sending the farm to
the addre s(es) above. also sWrinit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of wall construction to the county health department of the county
where constructed.
R.—rtW-1 Nottb e:mima Dcmtment ofEavaonm=W Ouality-Division of Water Resources Revised 2-22 2016