GW1-2021-02721_Well Construction - GW1_20210930

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WELL CONSTRUCTION RECORD(GW-1) For Intalsd Use only.
L�Well Contractor latiorrUation:
Ce Q,O�QiI� �0^ MWATIOMONIM
FROM TO DFSCRIPrIOIt
Well Contractor Name a�h ft- IL a
a`taa A �! R n
i
NC%%,all Contractor Certification Number Z5.OUTBR CASING mNtF d wed OR L}TtlUi e
Stephenson's Well Drilling, Inc. FROM RMHUM MATMAL
Company Name d r IL ` a- �I in. �ARat
2.Well Construction Pernft#: `� O O 26.IIVNSR OR TUBINGsI
FR03i TO DIANtBTER TlD'CI� Q,<ATERiAL
Fist all applicable wil eaasonaonpermAs Ae.DfC Couat%Sane Vadmm etc) tt.
3.Well Use(check well User
Water Supply Weil: FROM TO I DtAMM SLOrS= I TMCOMM I MATERUL
DASticulhu'd unicipaVINblic R IL -
Geothermal(Hcadng/CoolingSupply) 01tesidential,WaterSupply(single) I R tZ in.
[odustriaUCornmereW [[Residuals!Water Supply(sbered) 1&GROtTC
rAquMx
FROM TO MATERIAL EMPLACt1e41�i MEMOD&ANOMTT
upply went pour 5 r
R C� Jr,
ll: B &
harge DGroundwa cr itetnediation
i9.SANI1/GRAtrSI.PACiL cable
Agaifer Storage and Recovery [!Salinity Barrier FPAM TO I MATERIAL EMPLAt T AIMOD
AquiferTest OStotmwaterDtainege & & 1 t
DExperimental Technology OSubsidence Control R tL
Gwthamd(Closed hoop) [3Tracer, X DPIX mG lAG attaeh ad streets ffnecenaM
Geothermal Coolie Retum Odhr:r( lainunda-Ml Renaults) FROM TO Ola sor mithedr
ftmwfindmcW
4.Date Well(s)Completed: \- �- Wei!ID# n• n' KQA C
So.Well Location: %r0 r\ I ki Jb 11
C.T rf rkc.r— Po;n`l'e.
Faoility/thvncrName FmilityIM(ifapplicable) ft IL
4 S`l Asklev Vitw Lone, 4X�o�� a1565 Lgt�) '�
Physical Address,Cory,and
2LREMARKS
County Pared idemifioat[on No.(PIld) infnnnation ProCessing Unit
DWR SeciiOn
5b.Latitude and longitude in degreeshniout a alsecoods or decimal degrees:
(ifwall field.one ladlong is sufficient) Z-Celtifit�fon:
3 e 14 i 3-1 N 1�� 3l � Steil W
T. � IS
6.Is(are)theweu(s) Permanent or Temporary S' WcUCoutraemr Darr
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By sVft this farm.l hereby w fy than eke twelf fs)um(nael a mtracted in atrnrdance
7.Is this a repair to an existing well: [3Yes or�&O dM ISB NGIC 02C.0100 or ISA NCAC 02CAM weff Caasrrucoan Standards and that a
(fthts is a reparr.IN out kao-uzgeoartruetioa information and esphmt denature ofdm con'rfft Mmrd hasbewp vvMMto tltemdt oaater:
repatrunder#21 reatarlsseadon or on die back gfthtaform
23.Site diagram or additional well deters:
8.For GeoprobelDPP 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. ladicate TOTAL.NUMBER of wells cons vaction detat'ls. Yonmay also attach additional.pages ifnecessary.
drilled: 1 SUBMMAL lNsmuc TONS
9.Total well depth below land stniace: 3�) (�) 24a.EM All Wells: Submit this farm within 30 days of completion of well
Form file tvei&I&aAdepthsif&ff—I(mmpie-3@200'w d 2VOM construction to the following:
10.Static water level below top of casing: 3® (ft) Division of Water Resources,IDformation Processing Unit,
If%van rlevelisaboreeaon&use`+" 1617 Mail Service Rhleigh,NC 27699-1617
11.Borehole diameter.-. Q OQ 24h.For Intectition Wells Un addition to sending the form to the address in 24a
: /Q Q
12.Well construction method t r 1 qj o.c V above,also submit one copy of this form within 30 days of c mpledon of well
(;.e.augcrr rotary,cable direct push,W-) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resource's,Undergmand Trajection Control Program,
1636Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)a�_Method of test: Alta e.. 24c.For Water S Ady&blection Wells: In addition to sending the form to
the addiess(es) abom also submit am copy of this farm within 30 days of
13b.Disinfection type: RT H Amount: Ih. completion of well co nsm.,don to the county health department of the county
-brae constructed.
North Carolina Deoarimem ofEnviroameotal Oaalav-Division of Waterltesourm Revised2-22 2016