GW1-2022-05900_Well Construction - GW1_20220627

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Informations
14.WATERZONffi
Well ContractorName FROM To DESCRD'71ON
CSPM
NC WellContmaorCertificationNmnher 15OUTERCASINGformolfitosedrvells OR LINER lteaide
Stephenson Well Drilling, Inc. FROM TO DYAentrER TmCKMEss MATERIAL
Company Name Q ft --)- 1 is a v
16.HgNMCASING OR TtIBIIYG dose"oo
2.Well Construction Permit#: "� mom TO DIAa►IarER TIOCKNESS MATEtttAL
List au applicable nvil consductfon petmitr r e MC,Ca m%Stag Valiance,etc) AJ in.
3.Well Use(check well use): ft ft I°
Water Supply Well: lO.SCREEN.
FROM TO I DIAMBTER SLOTSUE TfnCIDKMMM MATE6MAL
i Agricultural DMunicipaMblic tL 3�s n, In.
Geothermal(Heating/Cooling Supply) 1OResidential Water Supply(single) ft. ft
Industrial/Commcreial OResidential WaterSupply(shared) ig GROUT
�Jlrrijzation FROM TO MATERUL ENMACEME M MOD&AMOUNr
Non-Water Supply Well: S3 ft cX® ft: h ` SM bmir
Monitoring Rcco % M
Injection Well: ft. ft
CJ}�► J
Aquifer Recharge �GroundwaterRemcdiatian
Aquifer Storage and Recov D(�smaini Barrier FROM
PACK rlteabte
Q g � IJ' ty � FRObf TO MATERIAL HNPLACthMTMETROD
i Aquifer Test OStomtwaterDrainage AIM R' %
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) OTraeer 20.DRiLI.IiYGLOG attach additiond sheets iF
Geothermal(Heathl Coolie ROhM1) MOther(explamundcr#21 Remarks) FROM TO Dltsts wrioN tutor ww aelc Sim otn
� �Q + � ft I % .� �'d't
4.Date Weil(s)Completed:��Well ID# ft. ft s p - e 1 A
Sa.Well Location: J ft 6 ft SA r1 r O C 1k
Facility/OwnerName Facility MN(ifappiicable) ft f4
ft. fL
I M bwje, lkck' Cre?e Maetr Wit, a-lsaa.
P` g" 1 a lhhyy-sicaall Address,C M and Zip
�V I II\/ '2LREAMIUR,
\
County Parcol Identification No.(PII� nt
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient) 22-Certification:
Y=" � ' 3�1► N 1 0' aC�t1 W
-%-an.
6.is(are)the well(SOPermanent or OTemporery sigitaukrowleaflffica Well Connactodj Date
By sigtiog rhir form.I hereby eetdJy that the neR(s)Ivan(were)cmtstructed in accordance
7.1s tbis a repair to an e7listing well: rjYes or.dNo uO ISANCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a.
Ijtlds fs a repair,fdl out known wdicanstructlon information and eipla n the notate of die mPJ'ojthis record hasbrat provided to fheivell mtiaer
repair under h21 remarks section or on die back ofthisform
23.Site diagram or additional well details:
6.For GeoprobelDPT 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 ofwells construction details. Yon may also attach additional pages ifnecessary.
tlrflled: 1 / SUBMITTAL waRULTIONS.
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jd fferent(—ple-3Q200'and 1Q1001 construction to the following
10.Static water level below tap of casing: (M) Division of Water Resources,Information Processing Unit,
Ifwpter levells above car mg.use"t" 1617 Mnil Service Center,Raleigh,NC 27699-1617
11.Borehole diameter_ (in) 24b.For Inlectfon We1Is: Tn addition to sending the form to the address in 24a.
12.Well construction method: A`I c Mtr>,f Y above,also submit one copy of this form within 30 days of completion of well
(Le.auge,rotary.ry.cable.dnect push,etc.) construction to the following:
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 testy ewe, 24c.For Water SDDDIV&Ifilection Wells: In addition to sending the form to
the addtess(es) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: T Amonn>; 1b, completion of well construction.to the county health deparimeat of the county
where constructed.
a,..,,,r1w.1 North Cantina De natment ofEnvironmeotal Ou&Hty-Division of WaierResources Revised2-22 2016