GW1-2022-08311_Well Construction - GW1_20220519

0
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
L Weft Contractor information:
14.WATER7.ONSS
tBWN TO i—M.-RWHON
Wc1lConhactorN e
IS � Sao % I IQ G rM
NC 1h'eli Contractor Ca6ficadon WMAW 15 OUM 94MG mnitltased WM OR LIIVER Iit able
StephensoWs Well Drilling, Inc. ,:Rohr To DIAll�rl�t Trnclnta S MTERUL
CnmpatryName 1d � I t in. sNN a1 P, �
16.1NNERCOINGORTUBINI3 thermald
2.Well Construction Permit* � � FROM TO I MAtVlErM THWICNFss I MATEBiAL
List all applicable wdl construedonpmd's(fie UIC Coma}:Stm4 Vad-M etc) Al fL % ht.
3.Well Use(chechwell use}: R'11. fie.
Water Supply Wen; FRS `
FROM TO I DfAMEtER SLOTSiZfi 'rHIwass' t17ATEntAL
Agdculttnal MunicipaUPublic tt: 1G In.
Geothermal(Hcatinscooling Supply) csidcntial Water Supply(single) f4 f. �-
IndostdaVCommercial OResidential Water Supply(shared) .1&GROUT
Flirrigation PROM TO MA7F.EtiAi. E ff"CEItII"blErMD&Ah1OMT
Lrtou-Water3upply6Ne11: R •F.nI n .� 1b �r
Monitoring Rtxovtay fi. fG -
fnjection Well: � �
quiferRechargeGcotmdwaterRemediation
l9jAND/GRAVELPAC1CffM� lEcable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO I xAr:Eltut to ACENl>th'ratsTl OD
AqufiferTest QlStmmwaterDmi=geAf IA
admental Technology OSubsidence Contm! R IL
Geothermal(Closed Loop) OTtacer 2A:DRlLLI1VGLOG attach addIWroalsheetsifa�essa
- Geothermal(HeatinglCooling Return) Other( laiu under#2l Remarks) FRo1vl TO DFscnit?TtoN mto�n snntmek isa cte
fi: tt:
4.Date Well(s)Completed: 1 - Well IDp n'
Sa.Weu Location: fL 3 0 G K
% fL
FacilitylownerNatne FaeiliryID#(ifappffcable) tt %
ft fL
Physigl Add[ess,[:ay.and Zip fi: fL g^+ y y 'A
Cr ro,ny 21.REMAIM- ,Tv 622
County Parcel ldeatifiwdonNo.(PRO
�,fN
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees: ,-„ SRi
anelatilon issuSdent EU a`;,) �:,a,, Ji�l
(ifwcm field. )) 2Z Certification:
-'�C J l pill N ��d � ' 1/ W
6.Is(an)the well(s)OPermnnent or Temporary s Well Contrar7 r Date
v Bp signing thisjotru I hereby txrrily_dtat die nt'll(s)war(me)coastraeted is m eordmtce
7.Is this a repair to nn UMiDgwell: Dyes or 4&o uith lsANCACOZC-0)09 or15A.NCAC 0217.QZDO Nell Censtrrrctlan Standardr and that a
lfd*is arepatr,fdl authaorwr twff ea umxlimd itformadmand esplaia thenatme ofdhe copptfth&rernrd hasbeea prov1&d to ft im!l mmer_
rVair under#2l remarbsec ion Oran dteback ofthisfarm
23.Si6e diagram or additiunell well detar7s:
a-For GeoprobeMPT or Closed-Loop Geothermal Wells having the same Y611 nab" bates of this;page to provides additional well anti:details or.well
eonstmcdon,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells constmetitm details.Youmay also attach additional pages ifnecessary.
dt�led: 1 LL sIJB1VIITrAI.INSTRUCTION
9.Total well depth below land surface: - l 00 24a.For All Wells: S&mit this farm within 30 days of completion of well
Formaltlple wells lhl alid4dk ff,W--1(emmple-3Q200'and 2glOD9 eonsimcdon t0 the following:
lo.Static water level below top of casing: -(fL) Division of Water Resources,Information Processing Unit;
Ifiraterlevel is above easing use (+ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ` , (iD.) 241L For Infection Wells: In;addition to sending the form to the address in 24a
12.Well construction method: Y`I r above,also submit one copy of this form witbin 30 days of completion of well
(Lr`auger;mmry,rrblt7 dkm pusb,etc.) ! construction to the fallowing:
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma11 Service Center,Ralelgb,NC 27699-1636
13a.Yield(gpm) Method of test: - IM S., 24ts For Water Simuly&fniegtion Wells In addition to sending the form to
1 the addresses) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Amount; completion of weII constntctlIm to the county health department of the cmmty
where constructed.
F,,,,,,M-t NorthCamlmaDcoutmentofEndmnme WOuality-DnmmofWaWRwouwes RvAsed2222016