GW1-2021-00193_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW J) For Internal Use Only:
1.Well Contractor Information: L
z e, \ �c e-V 1 ' ����11 e.h'�.�o - 14.WATERZONW
Well Contractor Name FROM TO DESCR1P110N
IL QSPM
��t�'� a6� a65
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NC Well Contractor Certification Number 15:OUTER CASING for mtdtl cash wens OR LINER Ueabte)
Stephenson's Well Drilling, Inc. FROM TO DULL1flrIPR ,� MATEtttAl.
Company Name ! ft- I in. V
1 1 1 16.nOnM CASING OR TUBIIY thermal eiosed400
2.Well Construction Permit#: 1 FRO TO DIAMETER TMCKN $ MATERIAL
List all applicable well consbrrcdonpermits d e.U/C Count}:State,Variance.erej ft' �•
3.Well Use(checkwell use): ft ft' 1n.
Water Supply We11: 17.SCPJZEN
FROM TO DIAMETER SIOrS= TffiCi ISS MATERIAL
Agricultural rIMtmicipal/Public NIA 'L ft, in.
Geothtxutal(Hcatmg(Cooling Supply) Residential Water Supply(single) ft, in.
Industrial/Commeroial Residential Water Supply(shared) 1L GROUT
Irrigation FROM I TO MATERIAL EMN ACFhmvr METEIGO&AMOmrr
[Von-Water supply well: � & aci R @ don; 'Nu a. !;7M6 kov
Monitoring Rtxovcry fL fL
injection Weth J
R fL
Aquifer Recharge DGmundwater Remediation
19.SAND/GRAVI"sL PACKOf a licable
Aquifer Storage and Recovery [►Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METROD
Aquifer Test OStormwater Drainage ft. tL
Experimental Technology OSubsidence Control fL fL
Geothermal(Closed Loop) DTmcer 20.DRII LING LOG attach additional sheets K
Geothermal(Heating/Cooling Return) ._ Other(explain under#21 Remarks) ts�� L
TMD DESSCRiP1101s mfor soivmeh si>z
It 0 s
4.Date Well(s)Completed: I _1 _aA Well ID# ft• Q ow
Sa.Well Location: ft-
ft. R � J'o\
MCA ' r� U► r v4sor I-We 3°� a.$S '�
Facility/OwncrName Facility IDd(ifappticablc)
ft. !Z
`t S6`Z M0.yf iel� 1_o.ne, �ro.nK��n`�o�11S� fL
Physical Address,Cry.and & !Z
crranV;lit- 1$`�6001��q —3 21."MARits
Tr
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I i {41
(if Well Held,one lattlong is sufficient) 22.Certification: �u litd.'
6 ls(are)the well(s).oPermanent or Temporary Si§aituld WCatilled well Connac r Date
By sigtriag this form,l hereby cvtfy tzar Me weil(s)was(ivere)cotaoncted in accotdatice
7.is this a repair to sit existing well: [3Yes or j?)No pith 11A NGIC 02C.0100 or ISA NCAC 02C.0200 Weft Consbuetion Stoudards and tzar a
Ifthis is arepain fUl out known tw11 construction informagm and espldn the nature ofthe ccW ofbhisrecord has been provided to the!tell ouster.
rrpdr under#21 remarks section or on the back ofthtsfmm
23.Site diagram or additional well detar7s:
&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 land sw faw �� (�) 24a.For All Wells: Submit this form within 30 days of completion of well
For tnulaple wells list ail depths ifdtfferent(esample-3e200'and 1QI001 construction to the following:
10.Static water level below top of casing: 3® (fL) Division of Water Resources,Information Processing Unit,
If rvaterkvel is above casing„use"+" 1617 Mail Service Center,Raleigh,NC 7709-1617
11.Borehole diameter: ^^ fin.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /'t 1 C 1"\0�0•f�► awve,also submit one copy of this form within 30 days of completion of well
(ie.auger;rotary,cables direct push,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
ry 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: 0,kA 24c.For Water Supply&Infixtion Wells: In addition to sending the form to
the address(es) above, also`submit one copy of tins farm within 30 days of
13b.Disinfection type. Amount: b. completion of well construction to the county heath department of the county
where constructed.
F.—t;W-r North Carolina Dcoattment ofEnvirownental Ormlity-Division of WaterResew s Revised 2-22 2016