GW1-2021-02723_Well Construction - GW1_20210512

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1..-Well Contractor Information:
14.WATERZONES j
Well Contractor Nance� FROM TO DFSCRIMON
���IL
14a'o� /[�—\ M fL
ft. tG
NC Well Contractor Certification Number
15.OUTER CASING for Fuld-cased wells OR LINER rf a llcabie
Stephenson's Well Drilling, Inc. FROM i TO DIA MTM I TMCXN ss I MATERML
�. ft I in. SD R ai P V L
Company Name ? r 16.INNER CASING OR TUBING eothermal dosed4o
2.Well Construction Permit#: J��\\qj� FROM To DtAMRreR Tinc[ct�irss MATERIAL
List act applicable will coast action permits(Le.UiC.Count}:States Variaaca era) AII ft• i°
3.Well Use(check well use): ft
Water SnPP1Y Well: 17.SCREEN `
FROM TO MAMETER SLOT SITE TMCKNFSS MATERIAL
Agricultural M micipallPublic tL ft, ; is
pGeothermal(Hcating/Cooling Supply) .oRcsidential Water Supply(single) fL M [o
industrial/Commercial DResidential Water Supply(shared) i&GROUT .
irrigation FROM TO I MATERML EMPLACEMEW METHOD&A6IODNT
1Von-Water Supply Well: ft. R C f 1 U S(0116 R x
Monitoring DRccovery ft, ft
injection Well:
i Aquifer Recharge E)Grotmdwater Remediation ft.
19.SAND/GRAVEL PACK f a livable
Aquifer Storage and Recovery QlSalinity Barrier P
TO MATERIAL EMPLACEhrEAT METHOD
Aquifer Test OStormwater Drainage ft. ft•
Experimental Technology Subsidence Control M ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if
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- Geothermal(Heating/Cooling Rolm) M Other( lain under#21 Remarks) FROM TO DFSCRWnON color,hadam soMroek rn s;zq c-
% —� f
4.Date Well(s)Completed: 2L;f Well ID# ft. 3 ft.
Sa.Well Location: 11 3d n ft• owr\ ro^au f01
CSce_Sho.,M �O►nl � LUZ, ft. 2.65 '� ocl�
Facility/OwncrNamc Facility M#(ifapplicablc) ft. ft
Lai �� r�tl.� L0.r\P, ok�o�� at1 S6s ft. ft RLtjC1
Physical Address,City,and Zip ft• ft.
C5 ro.rv'n II er 1°�3ocx���36a1 21.REMARKS
County Parcel Identification No.(PIN) .v fjtli`
t `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t NR Sf- r^r
Cif weld field,one lat/long is sufficient)
cient) / // 22.Certification:
N 7V0 3t S2. W T
6.Is(am)the well(s)) Permanent or DTemporary S; ed Well Contras Date
By signing this form,I hereby cer(ify that the net(s)ivar(were)constructed in accordance
7.Is this a repair to an existing well: DYes Or.dNo pith ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fdl out known rveUconmziction information and explain tie nature of the copy ojthis record has been provided to the cell owner.
repair under#21 remarks section or on the back of this form. 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 tbis'page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may,also attach additional pages if necessary.
drilled: .1
a�5 SUBMITTAL INSTRUCTIONS
9.Tonal well depth below land surface: M) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdfferent(example-3Q200'ond 2@loo)
construction to the following:
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10.Static water level below top of casing: 3 (ft) Division of Water Resources,Information Processing Unit,
Ij,vater level is above casing use^+^ 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 24b.For Iniection Wells: W addition to sending the form to the address in 24a
/� above,also submit one copy of this form within 30 days of completion of well
l2.Well construction method: `I f �0 0"r\l construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
^WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Ch Method of test: Q 24c.For Water SmmIv&Miection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fowl within 30 days of
13b.Disinfection type: h M Amount: I h, completion of well constructi 'to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Envirommental Ouality-Division of Water Resol.cs ; Revised 2-22 2016