GW1-2021-07537_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. - --- --
1.Well Contractor Information:
\"I Q.tjk�Y\J-O 1'\ la:WATER ZONES
L
Well ContractorNalme FROM TO DESCREMON
3,S R , a Qrph
R R
NC Well Contractor Certification Number 1S.OUTER CASING for mnitl-cased webs tf OR LINER Rcabie
Stephenson's Well Drilling, inc. FROM TO ANEIER I THICKNM MATERIAL
ft. -, R �1 in. $ a) PYCG
Company Name 16.INNER CASING OR TUBING(apothermal dosed-lo
2.Well Construction Permit#. 3a_(l\p O Q--\ FROM TO DL4LM 1111004M MATERIAL
List all applicable well constuction permits f e.UIC.Coup%State,Variance,etc.) R ft. in.
3.Well Use(check well use): R R in.
Water Supply Well: 17.SCREEN. .
FROM TO DIAMETER SLOT SITE TI(ICKN SS MATERIAL
HAgricultural OMunicipaMblic R ft. I in.
Geothermal(Heating/Cooling Supply) -IResidential Water Supply(single) It, R in
Industrial/Commmial DResidentiat Water Supply(shared) i8.GROUT
irrigation FROM I TO MATERIAL EMPLACEMFNT METHOD&ANIOUNT
Non-Water Supply Well: ft' Q Ot .r'
i Monitoring QRecovcry R R
Injection Well: r
R R
r-lAquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK rf ltmble
q g ery tY FROM TO MATERIAL EMPLACEMEII"TMETHOD
Aquifer Test DStormwater Drainage ti A
ft. R
Experimental Technology OSubsidence Control R R
Geothermal(Closed Loop) Tracer 20.DRIIIJNG LOG attach additional sheets Rn
Geothermal(Heating/Cooling Return) nOther(cxplain under#21 Remarks) FROMI TO DESCRIMON color,horenen,soWroek w s=et,-1
—1 E� ftt,-
R I J
4.Date Well(s)Completed: 1" 3d`a� Well ID# ft
35- ft• P G 0.Sa.Well Location: 6-` R 1' p'
11
1 y I R
CANT 0.�Q,CnP� '� C-V h`1'�l�l o� Cj f L�'r t r�
Facility/Owner Name Facility ID#(ifapplicable) ft. fL
I��l `fa�h1 Hol��1 Oxford �tC. a'1s6� ft. R
Physical Address,City,and Zip ft. ft• 1
Cyro Ay:11t. \J DlaS3°\ 21.REMARICS
County Parcel Identification No.AIM �S8in 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Jn Ov R Sec�O
(ifwell field,one lat/long is sufficient)
Q (4 1 r 22.Certification:
-3�� 131 ,511
J '/ N � J�" W
-1- 30- aI
6.h(are)the wells) Permanent or Temporary Si Well Conbactor Q Date
By signing this form,I hereby cerhfy that the wells)was(rvere)corutructed in accordance
7.Is this a repair to an existing well: Dyes or,mNo with 15A NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform
23.Site diagram or additional well deters:
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 only 1 GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' SUBMITTAL INSTRUCTIONS
9.Total well depth below sand surface: 3 1- (R) 24a, For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferertt(emmple 3Q200'apd IQI001 construction to the following:
10.Static water level below top of casing �® UP Divislon of Water Resotrces,Information Processing Unit,
ljtwater level it above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._rIZI-N _(m.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: i t-
P�O�Ar�� above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,directpusb,etc.) I construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) OL Method of tesC AU Q, 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also`submit one copy of this form within 30 days of
13b.Disinfection type: HT N Amount: '�. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Ouality-Division of Wateritecources Revised 2-22 2016