GW1-2021-02106_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. i --
1.Well Contractor Information:
-:SeiE9 V -T. 14.WATERZONES
Well ContractorNaAte IFROM TOift.
DFSCRIMON
Aft ft. Gem.
f
NC Well Contractor Certification Number 15 OUTER CASING for multitased wells OR LAVER ilcabie
Stephenson's Well Drilling, Inc. FROM TO D�� d� MATTE�RUL
Company Name
4 l ff. 61 in. s pR c�.� t Y
� l` 16.INNER CASING OR TUBING eothermal closeddoo
2.Well Construction Permit& 3Sap\% 'C FROM ' To I DwMEM T>nCKNM MATERIAL
List all applicable ivell construction permits r e.UiC,Count},Stab Variance.eta) M ft in.
A113.Well Use(check well use): ft. 'O
Water Supply Well: 17.SCREEN
FROM TO I DUKErER A SLOT SITE I T—M—C—KNTm--q--T MATERIAL
Agricultural 01dunicipal/Public ft, ft•
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) tt in
Industrial/Commercial DResidential water Supply(shared)
1&GROUT
--11irri2ation FROM TO MATERIAL EMPLACE 1RTrMM0D&AMOUNT
1Non-Water Supply Well: ft oZ ft' /V a lA
Monitoring DRecovcry ft. R
Injection Well: C�1
ft. %
Aquifer Recharge DGroundwater Remediation
CK
Aquifer Storage and Recovery O$al[nity Battler 19:SAND/GRAVEL PA if alikableFROM TO MATERIAL EMPLACEMENT NMTROD
Aquifer Test OStormwater Drainage ft- ft
Experimental Technology OSubsidence Control ft. it
Geothermal(Closed.Loop) Tracer 20.DRII.LING LOG attach additional sheets Knecess
Geother (Heating/Cooling Return) -_ Other( lain under#21 Remarks) FROM To DESCRipriON color.hardnm,smltmek
mal
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4.Date Weil(s)Completed:o a-QA Well W# ft' ft e q►1 G A
Sa.Well Location: $ ft. ft rQ�I n Sp` ( -P D 1
ce,ll�c�h.•PSJt`n�e- LLC -ta ft. aasft.
1-7
Facility/Owner Name Facility 1DO(ifapplicablc) ft. it
.mot -TC-1 E-W'Iv Late li�hfOrlly N L. a1 sus ft. ft.
Physical Address,City,and ' ft. ft.
n
zozi
t-ov\v;lle. 1°�3C�o101q°�1ao 27.REMARKS-
County Parcel Identification No.(PIN) _ Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' e d'011
(if well field,one lat/long is sufficient) 22.Certification:
3S° I�#/ �`X N 1 3I/ SDI, W 1 _a_
r-A M%;� I
6.h(are)the wells) Permanent or Temporary Si~oTCertiffed well ConfractorU Date
By signing Ibis form,I hereby certify that the ne!!(s)wvas(ivereJ constructed in accordance
7.Is this a repair to an existing well: Dyes or';�No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fdtout known well construction information and eVidin the nature of the ropJ-ofthis record has been provided to the well owner.
rrpair under#21 remarks section or on the back of thisforaL
23.Site diagram or additional well details:
S.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
consttuctiop,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' ;k 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 ifdrfjerent(example-3 a�00'and 2QIOD� construction to the following:
10.Static water level below top of casing: 3Q1 ot.) Division of Water Resources;Information Processing Unit,
If rater level is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. (#D.) 24b.For Injection Wells: In!addition to sending the form to the address in 24a
12.Well construction method: i C T�O�
pp F 1 above,also submit one copy of ibis form within 30 days of completion of well
V
(Le.auger,rotary,cable,direct push,etc.) construction to the following 1,
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test- Q0A 24c.For Water Supply&Iniection Wells: In addition to sending the form to
1 the add=(es) above also stibmit one copy of this farm within 30 days of
13b.Disinfection type:��� Amount: !�• completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department ofEavuonment d Ouality-Division of waterRewunxs i Revised 2 22-2016