GW1-2022-05814_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
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1.Well Contractor Information: 11 j
��.`�'��Q�l 1 • S`�e.Dh2 f()n 14.WATERZONFS I
Well Contractor Name FROM TO DESCREMON
:)L'u IL Duo n C Cs m
NC%ell Contractor Certification Number 15.OUTER CASING for mNti-cased weIIs OR LINER t[ hirable
Stephenson's Well Drilling, Inc. FROM TO DIMtEPER TW-L— I MATERIAL
Company Name
0 iL I 0\� fL t in. I SDP\a.l I PVC
A I /� r l 16.INNER CASING OR TUBERG thermal dosed-loop)
2.Well Construction Permit#: /V /1 CZr01 t 01\" FROM To DIAMErE11 TMCKNEss IMATERiaal
List all applicable well construction permi f.e.U1C.Count}:St Variance,eta) A11 fL m
3.Well Use(check well use): ft. ft. 7D
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSUZ THIC10,rESS MATERIAL
Agricultural DMunicipal/Public ft, ft. in.
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) ft. ft, to
Industrial/Commcrciat OResidential Water Supply(shared) I-&GROUT
hri lion f RoM TO MATERIAL FAFLACFIY ENT METeOD&AMOUNT
Non-Water Supply Well: ft' a o_ Pour 10 10 b 134ASi r
i. Monitoring DRe—cry IL &
Injection Well: f
Aquifer Recharge 013roundwaterRemediation It. ft.
19.SAND/GRAVEL PACK tf a likable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENIT A'iMOD
Aquifer Test Dstormwater Drainage MIA ft. IL
Experimental Technology OSubsidence Control It. It.
Geothermal(Closed Loop) Tracer 20.DRII.LWG LOG attach additional sheets K,' Geothermal(Heating/Cooling Rebirn) nOther(cxplainundcr#21 Remarks) FROM 1TO DFstauertON color,bardna%soiumck tqw,stmia size etc
ft. ft. J,
4.Date Well(s)Completed:�` -0�1 Well ID# ft'
5a.Weli Location: ovi tN f A n
it• 3a S It, oc _
Facility/OwnerName Facility 1D#(if applicable) ft• 2 "r.C U :'^a/
36S�b IJ C N4.i�c SCE �[cc n��jr.Ton �L;C. �lSas ft. fL
Physical Address,City,and Zip ft. tL
QT(O,r\xi 1,� 21.REMARK3: 2r^;r Pr w
I Unh
County Parcel Identification No.(PIN) �3'ys'1Q,/BOG
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field,one lat/fong is sufficient) 2L Certification:
N _,7%Q 3tA/ 11111 W
6.Is(are)the well(s) Permanent or OTemporary signabdrc orz Date
By signing this form.I hereby certify dial the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or loNO with ISA NCAC 02C.0100 or 13A NCAC 02C.0200 if'ef Construction Standards and that a
lfthis is a repair,fill out known well constriction information and explain the nature of the ropJ'ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Qosed-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-i is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional ages if necessary.
wed' .1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit:this form within 30 days of completion of well
For multiple tvelis list all depths ifdt�erenf(erampie-3Q200'and IQ1009 construction to the following
10.Static water level below top of casing: C7. (M) Division of Water Resources,Information Processing Unit,
lfivater level is above casing.use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 24b.For Iniection Wells. i
i1n,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
lZ.Well construction method: t jr11Q�O�f construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
(+ f
13a.Yield(gpm) Method of tesk \1 R lq fie, 24c•For Water SuDDIv&"iection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this fora within 30 days of
13b.Disinfection type: BT Amount: completion of well construction to the county health department of the county
where constructed. i
Fmm OW-1 North Carolina Derrarlmem of F.nvinnuneMal Ouality-Division of WaterRcsources Revised 2 22-2016