GW1-2021-02726_Well Construction - GW1_20210512

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WELL CONSTRUCTION RECORD(GW=1) For Internal Use Only.
1.Well Contractor Information:
,4e,r) .e,t N-r o r< it�o ATERZO ES Dasctu> KtoN
well contractor
��t era. A 400 " 400 '�
&
NC Weli Contractor Certification Number IS.OUTER CASHIG 11brr maltltased wells OR LINER Ikabie
Stephenson's Well Drilling, Inc. rROM TO DFAbD:TPR Twaawm MATERIAL.
© IL tt. 6 1 In. s p a1 (� L
Company Name
16.IIYIYSR CASING OR TUBING doreeddoo
2.Well Construction Permit#: 3 FROM TO DtAME M I THICKNESS MATERIAL
List all applicable rue/l construction permits d e.UiC,Cou tr.State,variance,etc) A ft. % tD
3.Well Use(check well use): % h'
Water Supply Well: 17.
FROM TO DIAMETER I SLOT SM THICKMW I MATERIAL
Agricultural OMunicipal/Public R, R, in.
Geothermal(Hcating/Cooling Supply) oRosidential.Water Supply(single) ft. fL In.
ladustrial/Commercial DResideattal Water Supply(shared) Is.GROUT
—h-rigation FROM TO MATEM" EMPLACEMENT METHOD&AbrOUN T
Pion-Water Supply Well: " ao z A'1 Alfa,
Monitoring DRecavary R it Ch
Plojection Well:
ft ti.
Aquifer RechargeGrotmdwater Remediation
19.SAND/GRAVM PACK ieaMe
Aquifer Storage and Recovery Dsoinity Barrier FROM To I NATMTAL METHOD
Aquifer Test OStormwaterDminage ft• %
Experimental Technology Dsubsidence Comm, ft. ft
_.Geothermal(Closed Loop) DTracer 20.DRILLIiYG LOG atteeh additional sheets if
Geothermal(Heating/Coolin Return) F3Other(cxplainunder#21 Remarks) 6ROM To DESCRrnnON color, sonhvek eir-
t;. s. I f
4.Date Wells)Completed: s- I'�-a ID 1 well # n' 30 ft- Re S-
Sa.Well Location: y D' ft f OW h Soon S 0)
CSC�jI�C.►'r P(1 r1�1 e. L-�.C. � � �aS� a C
Facility/OvmcrName Facility M#(ifapplicable) ft. fL
T­rv:i1�
Physical Address,City,and Zip tt. R. Z
Qr ra,.V1 I y°v3z001CAl0j In 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/sewDds or decimal degrees: U n it
(rfweH field,one latnomg is sufficient) 22.Certification: D R se-clion
13-a1
6.Is(are)the well(SoPermanent or Temporary SiV%b='Wr3artiffcdVcl1 ConbactoY Date
By signing dds form,I hereby raet*dtat rite ueU(s)iau Ovm)constructed in accordance
7.Is this a repair to an existing well: E)Yes or oNo u7th ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standardr and that a
yddo is a repair,fdrout known well conetrmetion information and explain the nature ofthe cepJ'ofthis mord has been provided to the urll otmer.
repair under 021 remarbsection or on the back ofthlsform
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 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 ifnecessary.
mac' (� — SUBMITTAL IIVSTRUCTIONS
9.Total well depth below land surface: 1 a J (ft) 24a. For All We11s: Submit this form within 30 days of completion of well
For ma!liple wells lisr alldepthr ifdtfjerent(example 3(a�200'and 2QI009 construction to the following:
10.Static water level below top of casing: 3 0L) Division of Water Resources,Information Processing Unit,
If water level is above casing.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. on.) 241L For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one ropy;of this firm within 30 days of completion of well
12.Well construction method: t r eOlpsf construction to the following'
(Le.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) Method of test: QT A U 5� 24c..F r Water Sunaly&Infection Wells: Tn addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4T Amount: 4—D, lbs completion of well construction to the county health department of the county
where constructer.
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c......r:ar-r Nnrth rmnlina DenaMnent or Environmental Oualitv-Division of Water Resourtxs Revised 2 22-2016