GW1-2021-02329_Well Construction - GW1_20210722

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�+ tC91�ISTRUCTI® 1?RECORD f+a -1Z For lntemal Use N y:
1.Well Contractor Information: `
L�C�TT1 Qi1� ♦ �J �:IQ �+/�'Sfi}tl 14.SYATMZONE$
--e FHoat To DEsgftM toN
WcilCantractaritiamt: I Icy 6A
NC%left ConaacrorCertification Nurn'bor i
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LA'G(for mnirF-cased mlls)'OR LIPFEit Ilcabl
Stephenson's Well Drilling, Inc. 'ram �c�z�t-
CompanyName —1 D" 1. I ,n. W, al t V C
16.IP1NM CASING OR Tt16IN6 thermal closed-loop)
2.Well Construction Permit p: \j Fnaat ro Dtaas x ataTEruAL
List all app0cable u¢(t construcUotf jM=*&fl e.UX Count},State.Variance,ere) R• fl' 1°
3.Well Use(check use): D' n' in.
Water Supply Well: 17'SCRBBN
FROat To atM[ETER oTS[Z£ TxtctacEss MATERIAL
0Municipal/Public fL Itto
Geotlternal(Hcatit eiCoo)ing Supply} Rtxidcntiai Water SuFF1Y(s►n�c) JV rL rL �in.
IndustriaKommcrc"sal DRcs'sdential water Supply(shared) i&GROUT f
°litigation moat To MATEMAL rnntru METHOD&AMO(M
Non-Water Supply Well: Q ft. aQ ft
Monitoring l��at'ry & ft C�,
fniec on ell: ft. ft.
AquiferRecitarge DGmandumter Remediation 19.SAND/GRAVEL PACK a i'uxrbie
Aquifer Storage and Recovery QESnlinityBarrier MINI To MATtRML I MVLAc8at8lTAMTHOD
AquiferTest OiStoratwater Drainage D•
Experimental Techaalogy D&AxidenceComsat ft. It.
Creothennal(Closed LRDP) DTracer 20.DRILLING LOG attach additional sheets If neon
Goothenrai(HeatingJCooli Retrua) Other(explainunder M Remarks) M(M Tot
o DFSrxtiP7tgPt co}ortrardatssspittrack raiasine.
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4.Date Weil(s)Completed: ` ` Well Ll}# ft. Q,(� +ti,
Sa.Well Location. � � � � J0*1
11'21-k'ta s_1��►1�e.c S dv e,� L e,o,'F I 5� �, 5 ..
FacilitylOumertwtamo � 7 — Facility1139(ifapplicable) o'
!-At' IQ�" 1�oy�f�$.1� Lang Yoc>\ne-i'yille. �1S•"'��a o: fL
Physical Add—,City.and Zip % ft.
21.R MARKS E ma`s
G 01AV r��e� y , ;, °r
County Panxi identification No.(PIN) `f♦
5b.Latitude and longitude in dcgreesiminutes/seconds or decimal degrees:
C.rf♦voll Geld.one tatilong is sufficient) 22.Certification:
C�a 315 v 1` ° 331 � W
6.lg(are)Ilse VIEWS rormanent or Dremparary Sig&*mVtcaificdlWo1l contractor' V Dare
By signing this farm I hereby eenl&that Ike uslt(s)rear(rrerel canstrwed in accardance
7.Is this a repair"to an existing anti: OYes or�ZNa - ♦rilh j5A A'CAC 02C.0100 or ISA NCAC 02C-0200 Well Conetmetion Standards and drat a
zr&&irrrreiwlr,fill out 1-norm well caastruttion Infamlauon and explain the nature ofthe copy ofdus retard hug been provided to the uWl mvner.
repair under R21 rentards section or an the bad,gjthtrfornr. 23.Site diagram or addiflonal well details'.
&For Geoprobel7)PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
CofLMCfioR,q Daly I OW-1 is u=dcd. ludicatc TOTAL N MMBEit.of mcUs construction details. You may also attach additional pates if uecessaty
drilled: it SUBiALw L�iUGTIO1+iS
9.Total well depth below land surface: 3 eft) 24a. For AR 4V ; Submit!this form within 30 days of completion a;Weil
For mullipta wells rw all depths ifdoff-vat(example-3@200'and 20100) construction to the following:
10.Static water level below top of casing: (ft.) r3ft19on.of i't'atcr Ltesuurc:t�Information Processing Unit,
,[('outer level is abm a rasing.use-+.. 161711611 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: { •} 24b.For Inleetiot(_Wells.- in�addition!to sending the form to the address in 24a
c above,also submit one copy ofthis form within 30 days of completion of well
12.Well construction method i s R i f�� construction to the following:
0.1 auger.rotary,cobte.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,tiC 27699-1636
13s.Yield(e91I11) ._ Method of test: 0�u 24c. or Water Suno[r tA"Inftr lion 4itellsr 1n addition to sending the faro to
1 the address(es) above, also stibmit we copy of this Am uithia 30 dabs of
13b.Disinfection tz po: � Amount: 16 completion of well aanstnuctiaaj to the county health department of the county
where constructed.
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Form GW t North Carolina Department of Environmental Quality-Division of Water Res en= Revised 2-22 201 G
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