GW1-2022-09082_Well Construction - GW1_20220926

WELL coNsTRUCTION RECORD(GW 1) For Internal Use Only
L Well Contractor Information: II
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Well Contractor Nam -� r i c ''Cy ON
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NC 1A`eil Contractor Certification Number
!n; :y c :' r -d OUTER CASfNG m�ti=cased weIIs OR LIPIER d livable
Stephenson s Well Drilling, Inc. FROM TO DL�1tsrER '�` MATERIAL
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Company Name � as 16.INNER CASING OR
O\ TUBING thermal e[osed-,n
2.Well Construction Permit#: 3 O 6 FROM TO I DIAMETER J THiCit1FM MATERIAL,
List all applicable well consbuctioapermits(Le.U/G County.Stare,[far9m=ere-) 'L I
" In
3.Well Use(check well use): IL IL to
Water Supply Well: FR SCREEN
ROM TO I DIAMELER SLOTS= THICKNESS MATERIAL
Agricultural [:)MunicipaVPublic ft. in.
Geothermal(Hcatmg/Coohng Supply) 42 iRtsidentiai Water Supply(single) rL in.
Industrial/Commercial [Residential Water Supply(shared) itt GROUT
lirrigadon FROM TO MATERIAL. EMPLACEMEATMETHOD&AMOUNT
Non-Water Supply Well: <3 & oZ0 & Q7" U l l sQ JA
- Monitoring Retmvtsy fL It: 1.
InjectioaW
ell: ft R.
AquifechargeGroundwater Rt mtxliation
19 SAND/GRAVEL PACK i a livable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERW EntrLAeanlstvT METHOD
Aquifer Test OStormwater Drainage IVIA ft.
Experimental Technology OSubs"tdence Control ft
Geothermal(Closed Loop) Tracer 20.DRII.i.ING LOG attach addiitional sheets if
Geothermal(Heating/CoolingRetum) FDOther(explainunder#21 Remadts) FROM To DEscwrrtoN eolu::tmrdmu.amvraek r
ft. iG 012 f0'
4.Date Well(s)Completed: 1 b aJkWell ID# ft' O ft' C11 C 0\\
5a.Well Location: ft S % SQ\n
--S6hr-, SIo.1'or1 as' fl s !L NJ c 14 .
Facility/OwnerNarne Facility lD*(ifapplicablc) ft. ft.
Ml S Lake, l_,odt�, 'a& EA, hle r c�e(�On 3'1 s-3-1 ft.. ft.
Physical Address.City,and Zip ft. ft.
V Q4 saA 0 1 Q 0 ( 21.REMARKS
County Parcel ldenttficationNo.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ^ / 22.Certification: \
N ..��d d5, �bt/ W °\�13- aa
6.Is(are)the wells) Permanent or Temporary S' o ficd Contactor Date
33,S&dng'rhis form.1 hereby Gerd&that the ueafs) +xis frsem)'consirwed in accordance
7.Is this a repair to an existing well: DYcs or.ZN. udth 15A A*CAC 02C A100 or 15A NCAC 02C.b00 Nell Construction Standards and that a
1f this Ls a rtnair,fell out known well construction information and explain the nature ofrhe copy ofthis record has been provided to the well mmer
repair under#21 remarks section or on die back ofthisfarm
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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled 1 SUBMITTAL JNSTRUCT1014S
9.Total well depth below land surface: I ) 24a. For All Wells: Submit this farm within 30 days of completion of well
For mulliple well;list all depths Vifferent(trample-3Qn 200'and 2Ca110011 construction to the following:
10.Static water level below top of casing. 3(3 (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing.use"r" 16I7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Q } above,also submit tune espy of this form within.30 days of completion of well
I2.Well construction method: Al f f�0 I O�f 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,NC 27699-1636
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13a.Yield(wpm) Method of test: C;lh Ne_ 24c.For Water Sanely&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fart nfithin 30 days of
13b.Disinfection type: Amount: 1 bA completion of well cons6ction to the county health department of the county
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