GW1-2021-00187_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW=1) For internal Use Only. _
1.Well Contractor Information: T
7, ff r-Q--,i -T �t ��t e r� o r, 1, TER�_� Dist stPnot�
Well Contractor Name
NC l4'cll Contractor Certification Numbs 15 OUTER CASING for nmald-cased wdis OR LAVER IEtafiie
Stephenson's Well Drilling, Inc. FROM To DIA11MM Tffi MATERM
Company Name
Q fl. _3 tt. (G t in. l�(�a p v
-� 16.IVNER CASING OR T fJBIV al dosed-loop)
2.Well Construction Permit#: 7� `�� _��' FROM I TO I DNMErER I THICIa+,rFSS MATPer6r
List aS applicable well construction permits(i.e.UiC Cotuu};State,Variance.etc) ,4 "- it _ tm
3.Well Use(check well use): n• rL
Water Snppty Well: 17.SCREEN _
FROM TO D1A1rWfflt SLOTSEM THICIMM MATERL4L
Agricultural Municipal/Public rL ri. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) rL ft.
Indushial/Commercial DResidential Water Supply(shared) Is.GROUT
Irrigation FROM To MA7ERML EMPr.ACt MVfr'ast r WV&AMOUNT
Non-Water Supply Well: C\i �; R i Q puar5'��li C t,r
Monitoring Rccov�r M M C-k" .r
Injection Well: &
Aquifer Recharge DGtotmdwater Remediation
19.5AND/GRAYEL PACK f Hcable
Aquifer Storage and Recovery Salinity Barrier FROM To MAMTAL ENiPLACEhtFAT11tETROD
Aquifer Test DStormwater Drainage R• R• —
Experimental Technology ©iSubsidence Control tt ft
Geothermal(Closed Loop) Tracer 20.DRII L[NG LOG attack additional sheds if nece
eatin Cooling Return Otber( lain tender#2I Remadcs) FROM TO DWCR[MON(odor hmdnecs,sw11reckt e, sae.etc
Geothermal
a. to T Q , 0
4.Date Well(s)Completed: -, - \ Well W# n' y n S "t\
Sa.WeU Location: S `;`�
fil
raciiiryidwncrNanic Facility (ifapplicabic) e. tL
I5�0 PvubVn.1 F.id��„>,�f��le, LO�n�����ur4al ��t� f R.
Physical Address,City.and Zip R' fL
County Parcel Identifiaaion No.(PIN) —
5b.Latitude and longitude in degreestminutes/seconds or decimal.degrees: —
(ifwell field,one latttong is sufficient) 22.Certification:
N i s/ a%,, W
6.Is(are)the well Permanent
Permanent or Temporary si Well contractor' Daic
By signing this form.I hereby certify Char tine nell(s)was(here)constructed in accordance
7.Is this a repair to an existing well: Dyes or Z�No ntth ISA ACAC 02C.0100 or ISd iVCdC 02C.0200 Wehh Concoction Standards and that a
ifdris is a repay,fdl out Anortn nrehl construction informatian and a plain the nature of the copy ofthis record has been provided to the itchl inmer.
repair under 921 remarks section or on die back of thisform
23.Site diagram or additional well details:
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.
drilled: - SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(emmple-3@200'and 2@1001 construction to the following:
10.Statie water levee below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If inter level is above casing.use ((�-+- NUB
ll Service Center,Raleigh,NC 27699-1617
II.Borehole diameter. U (ln.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: A
[� c
1 i\Ut'\f above,also submit one copy of this form within 30 days of completion of well
i�(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: CN�A 24c.For Water Supply&Injection 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: 1 H Amount. completion of well construction to the county health department of the county
where constructed-
P.—r.W-1 North Carolina Dcoadmeni of Environmental Oualitv-Division of Watcr Resoums Revised 2-22-20I 6