GW1-2022-08784_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
14.WATERZANES
FROM TO DFSCR11M0?4 M Weil Contractor Name a00 (L ao® 1L ,r_O I•`
a� aa. A R a- V t
NC Well Contractor Certification Number 15.DuR CASING or m wells OR LIi+II;R tf s litahle
Stephenson's Well Drilling, Inc. FROM TO DIPAMfER THIt KlVFSS MATERIAL
Company Name ` V L
3 a31 16.1NNSR CASING OR TU6ING( �losed4
2.Well Construction Permit#: FROM I TO D1AVMR TMCKNEOS MJ4XF UAL
List all applicable wall cvratrursirmPernritr(Le-UIC Courr4=&amm irariw=etc) ZeA R' fL hL
3.Well Use(check well use): ft. ra
Water Supply Well: r-R SCREEN ;
FRO i TO I DIAMETER SLOTSIZ£ S'HICiINE.SS MATERIAL
Agricultural MtmicgtaifPubGC a- ft. in
Geothermal(Hcatmg/CoolingSupply) %oRcsidential Water Supply(single) R, in.
IndustriallCommercial rlResidential Water Supply(shared) 1&GROUT
irrigation FRO51 I TO fL MATERIAL EMMACt31ENrMETHOD&AMOUNT
Non-Water Supply Well: f" S791b bcow
DMonitoring 011ccovery 8. M ch�l f
Injection Well: A. IL
Aquifer Recharge groundwater Rernediation
19:SAND/GRAVEL PACK Iicable
Aquifer Storage and Recovery DSalinity Barrier 'FROM TO MATERTAL Ei1tPLACFIlrEh"r11tE7 FIOD
Aquifer Test oStorrawaterDrainage A11A R' IL
Experimental Technology OSubsidence Control R R
Geothermal(Closed Loop) DT-ear 20.DRII:I.iNG LOG attach additional sheets if
Geothermal(Heating/Cooling Return) nOther(explainundcr#21 Remarks) 1 FROM To DFscRnmON tutor,herdnem mnfaick •m sb=Nit
G .J• ' I
4.Date Well(s)Completed: a c),%Vell IDff
5a.Well Location: 65' So`�
urie,�l�o.. la�tll �s, ._44 5
c c .
Facility/0wncrNamc FaclityIDaffaMlicablc) D' R' C F7';k '
3-115 /".®ace-- Pond '(a"F..ry',JJe, 1'iS'7►6 ft. ft.Physical Address.City,and rap p t1 d D' % S E P Q D• O ZZ
F r A h b(1;!'1 I O 1 a.S i 3 p S 21.RER4ARI6S i
County Pared Identifitation No.(PIN)
5b.Latitude and longitude in degreeslminntes/seconds or decimal degrees:
(if well field,one ladtong is sufficient) 22.Certification:
6.Is(are)the well(s)PPermanent or Temporary Si d Well Cont aetor I Date.
By signing this form.I hereby certify drat the wells)was(rase)constructed in accordance
7.Is this a repair to an existing well: 0Yes or oNo n41h 15A NCAC 02C"0100 or 15A NC4C 02C A200 Well Constriction Standards and that a
lfdds is a repair,fall out brown ivell construction Information and explain Me nature ofthe copi,of this record has been provided to the well owner.
repair under#21 tamarb section or on die back ofthisform. '
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 nt eded.Indicate TOTAL NUMBER of wells construriiion delaih- You may also attach additional pages if necessary_
�— 4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � t ) 24a.)or All Wells: 'Submit,this form within 30 days of completion of well
For multiple wells list all depths ifdrjjerent(example-3Q200'and 2Q100� construction to the following
10.Static water level below top of casing. �© (ft) Division of Water Resources,Information Processing Unit,
Ifimter level is above easiag.use"+e 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. y (m.) 24b.For Inlection WeUs:i In addition to sending the form to the address in 24a
P above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A'I( �1oA(�I 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,N`C 276"-1636
13a.Yield(gpm) Method of test: A\A 24c.For Water SuoDty 8t Injection Wells: In addition to sending the form to
the address(es) above, also submit tine copy of this form within 30 days of
13b.Disinfection type: Amount: .1 1b. Completion of well constmction to the county health department of the county
.a.—. ..."+,, .a.r