GW1-2021-07540_Well Construction - GW1_20210903

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Wj`,L ,CONSTRUCTION RECORD(GW 4) For Internal Use Onbr
L Weil Contractor Information:
ce.�l laWATERZONES
FROM TO DESCRWnON
Welt Conbaetor Name 7 S' ft 'l r- % a 0 G M
�y as M rt
NC%%;cll Commctor Ccrti6cetion Number 1.►r OIITBR CA5MG mulB•tesed WM OR LilVlilt umble
Stephenson's Well Drilling, Inc. MM I To Dtj4m rmt I -nucur ESS MATER1Al.
C1 ft. 65 ft C'1 in. spK aI P vc
Compnmy Name I&ffe SRCASING OR TUBIIYM I TO D of dAMETM --A T aSa7FRIAL
2.Well Construction Permit*
at an a"U"N(e trap corafttcdm ROW's A&t11G COaano,Sera,Yadar=ere) N A ft- m in.
3.Well Use(check well rise): % n hL
Water Supply Wen: PA M TO D SsoTslzri rlaera�s` tftATtsRrAL
Agricultural [)Mtmicipa blic UA rG m rm.
Geothermal(HcatinglCooling Supply) Mesideodal Water Supply(sJn&) tt tt. lo.
IndustriaUCommerciat DResidandal Water Supply(shared) I&GROUT
lrri [ion FROM TO MATERM zKKACLmErgrbUwooDAAmouzvr
Non-Water Supply Well: fL �Q `f e 20U 10 50 b o► x
Monitetia m— C h' f
Injection W ft. %
t Aquifer Recharge Darounduma Remediation
19:SAND/GRAVSL PACK
Aquifer Storage and Recovery DswinityBarlier MWK TO MaTeRw. ERMAC MM"r a MOD
Aquifer Test OStormwaterDtaieoge At 1A it
perimental Technology C)S»bsidence Control Ift ft.
_Geothermal(Closed Loop) D rracer 20 DPJLU fG LOG attach additional Sham if
Geothernul(HeaftlCoolin Retum) Other{ iainmtder#21 Remattts FROM To D istmmly aontrodc etG
fR tt 0 ro
&Date Well(s)Completed:%- '"oLl WeUID# n' �Q & NQi G
Sa.Well Location: 30 n 6 d R h so j
Facility/OamcrNacue FacilityM#(ifopprreable) R
4-gao\ Rbbv..i Ln• Vwn Zlkofkulte.Wool- I-Qt I ft. tti
20
ft
Physical Address.cal. zip ft.
CTfAhV;Ile O°��00011 S 3 S� 21.REMARBS.
Co„„ Marcel tdeatilimd allo.( Informs 1 acton
County
5b.Latitude and longitude in degrem/minute s/seconds or decimal degrees:
(ifwcn field,one laUlong is sufficicat) 22.Certification:
N 1�.° 4a� 10`� W
6.ia(are)the well(s)OPermanent or [3Tempomry s well Cantrictor Date
By stgtiog rids form.!hereby term char dte tmeW rsas(Were)conmWed to accordm ee
7.Is this a repair to an existing well: mYes or.bNo ivtth ISANCAC 02C.0100 or]$A NCAC 02C AMO Reff Coasducimr&audan&and dat a
ljthFs isa repair,jiiioat lxmw taff eoasavaxion brfomratimtand esplabt rhenaturr ofthe mPJ'ofihisremrd has beptpsocddad to t/rntrliotsaer
repair under e21 rem ariaseuion or on die back oft&afarm
23.Sift diagram or additions[well details:
&For Geoprobe/M 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 constrrtctitln details.Youmay also attach additional pages ifnecessary.
dn7led 2 SUBMMAL INCLjRU(TIONS
9.Tate)well depth below bud stuhce: o (R) 24a. For AU Wells: Submit this form within 30 days of completion of wellForaarldpkts slistapdeprhsijfir�erent(emmpfe-33t�200'andl®1009 construction to the following:
10.Static water level below top of casing: ® (fL) Division of Water Resources,Information Processing bait,
Ijnarerlevet is above casin&use+" 1617 Malt Service Center,Raleigb,NC 2789-1617
11.Borehole diameter: (ln.) n -} 246 For Injection We115: In addition to sealing the form to the address in 24a
12.Well construction method: �t'I C 1'�b 10.f I above;also submit one copy;of this form within 30 days of completion of well
(m auger,rotary,cable,direct pus%etc.) construction to the follOwitlg:4
FOR WATER SUPPLY WELLS ONLY: Division of Water Resonrces,Underground In feeHon Contra]Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm.) Method of test: Ck 24c.For Water SnaDxv&InjectioD Welts In addition to sending the form to
,( ve,the addtess(es) abo also submit one copy of this farm within 30 days of
13b.Disinfection type: �� H Amount: .!- ,b. completion of well coriahuction to the coumy heahb departtneat of the county
where constructed.
F,,—r:av-1 Natth Camlma DenutmentofEnwotunente!ouality-Diyw=ofwetcrResootces Reeviseda 22 2016