GW1-2021-02743_Well Construction - GW1_20211130

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9VELL CONSTRUCTION RECORD(GW 1) For In»erl,at use only:
i.wen(contractor loformation: L
14.WATSRZONffi l
Wall Contractor Nanle I FROM TO DFSCm>�ti�t
NC Well Contractor Certification Number I5 OUTER CASING fformulfl-cased we h OR i�3VF.Ei t[ tECeitie
Stephenson%Well Drilling, Inc. MM TO MMMEM MMINO S MATERTAL
t:ompaayName ( sa,a- 1. sf)e' a C,
�y 16.INNSRCAMWOR G atcloRd[
2.Well Construction Permit#: 3 a lA a� D\ MM To MMETEt a erns MatF�w
List an gppllwbie hell awavvelanpermits(Le.NC County,Mam Yarfawc etc) tti
3.Well Use(cheekwell user n-
SCPJM
WaterSupplyWeZ: MOM TO I J)tj4bMM_j SLOt'SEM ItgaClae>•ss tvtaTpetnL
cultural rcrpa]/PubficIV 1A tL iG ln.
Cieothennal(Heaft*Coolmg Supply) •dual Water Supply(single) f m
Iadustrial/Commercial DRtsitimW Water Supply(shared) 18,GROIrr
rAquifer
FROM TO MATERML EIV�i.ACEMM[MrMMOD A AMOUNT
upply Well: � ao � t'I� 0/��Q, -r
vtxy R fZ Ch► J
ll: tt
b. DtanontdcaatenRemtetiiatioaage and Recovery Salinity Barrier FROM
RO�GRAOVYsL PACK Ma mie EMPLACEnnm'r MIM[oD
AquiferTest QlStonmwaterDminago R. (L
3Experimental Technology OSubsidau:e Control ft. %
ceothennal(Closed Loop) 0TIrIcer U.aRa.LurG LOG ateaeh additional simds KarA
Geothermal eatingiCoolin Ret mt ftw( lain under#2l Reactants) Lft.
oM ro ot?sCttwltoN(tutor tmeaat s.satthaat $a
O R- & -TO -r 0 I
4.Date Wel(s)Completed: l l-�a--M wen m# SS '� .ro'
Sa.Well Location: � D• %S fL
do
AtL tL
FacilitylOnnrcrNamc FaciGryIDb(ifeppficable) ft. M rD 1=.,•, .,1 5-.,g ,
CS i Caro,,. %6,,Mk Ottorj t�,c r'a�s6
ft IL
Physical Address.Cuy,and Zip R
aro�nok Oq°��t�OZ�4q�3 -R> ARIs`
County Parcel Identification No.(PiT>)
5b.Latitude and longitude in degreeshoinutesiseconds or decimal degrees:
(lf well field,one latliong is sufficient) 22.Certification:
3fjO �1 t �11 N ��O ��/ 11 W
6.Is(are)the wen(svpmment or [3Temporary Sigaht6redfMatiticil Well Contractor a Date
By s4pft rbfs fonm I6eeby caro Ilan due WdW)I—(am)CMB&Wed in amordanee
7.Is tbisa repair In an existing well: DYes or ONO ufth ISANCAC 02C.0100 orISA NCAC OZCA200 Nell Cmuwc6on Standunk and chat a
Ifdfs is a repair,fell outknoam swNcownucvian infonnadw and agAzin thenature ofthe cqD,afthirretard has been provided to tkearlt owner.
mpair under#21 matarkssertion or on the back gFddrform
23.Site diagram or add itTanal wen details:
8.For GeoprobelDPT or Closed-Loop Geothermal Welts having the same You may use the bacis of this page to provide additional well site details or well
tmnstrnetion,only i CrV+i-I is needed. Indicate TOTAL NUMBER of wells construction details You may also attach additional pages ifnecemay.
dtBled �- SUBtVIITi'AL_INS MUI CU NS
9.Total well depth below Ind surface: I (L) 24a.For All Werra: Submit this form within 30 days of completion of well
FormaWe wells I&afldo*Ifdde=I(emmphr-3e200'and 2@700 construction to the following:
10.Static water hovel below top of arcing: 34 (ft) Division of Water Resources,Inbrination Processing unit;
If imlertevet is above aasfi,A are-+' 1617 Man go-vim Center,Raleigh,NC 2709-1617
11.Borehole dlametrr. (in.) 241L For Iniemtion Wells: r1l addition to sending the form to the address in 24a
12.Wen consavaion method- A 1 r R��o�c y abovk also submit one copy,of this form within 30 days of completion of well
construction to the following:;
(La.auger,rotary,cable,direat push,tic.)
DwIsion of Water Rmurces,Underground bdecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 16361Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)— Method of te6C Sp�AcT 24,For Water Supply 6t Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.DIsinfecdontype: Amount:—A- 16. completion of well construction to the county health department of the county
where constructed.
V.—t:vr_t North Carolma Dena oflsaviarnmeotal Quality-Division of WatcrRe;otuar Revised 2 22 2016