GW1-2022-09825_Well Construction - GW1_20221028

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
I.Well Contractor Information:
FROM TO\! i S�t?.�� ns®r\ 14.WATERZONES
Well Contractor N DFiSCRIPi10N^�
ciem
c�L-4 c c�. � �® a 3p .3 cl F
NC'%'ell Contractor Certification Number 15.OUTER CASING for multi-cased was OR LINER tf e lit�ble)'
ETER rHIcttivEss -
Stephenson's Well Drilling, Inc. FROM TO DL M MATERIAL
fL 16 7 it. l in- I-S P V C
Company Name
I ��� 16.IIVi IER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM I To WAMEr6R I TFMCKNESs MATERIAL.
List all applicable well constructionpermits(Le.UIC Count}:State.Variance,etc) IVIIA VL fL in.
3.Well Use(check well use): ft. fL in.
Water SuAP1Y Well; t7.SCREEN-
FROM I TO I DLOU. R J SLOTSVE' I THICKNESS I MATERIAL.
Agricultural [3Municipal/Public At fL fL in.
Geothermal(Hcating/Cooling Supply) oRcsidential Water Supply(single) 0 ft, m in
PIndustrial/Commercial OResidentral Water Supply(shared) 19.GROUT .:
Irrigation FROM TO MATERIAL Ei1tF'LACEMENrME1HOD&AMOUNT
Non-Water Supply Well: R' au I, G 5
i- Monitoring []Recovery sL ff♦ C. ' __-- -
Injection Well: ft. fL
i Aquifer Recharge 013roundwater Remediation
19:SAND/GRAVEL PACK rf si livable)
NAquifer Storage and Recovery QlSulinity Barrier FRo TO MATERIAL EMI ACEMENT METMOD
Aquifer Test OStormwater Drainage At A R• %
Experimental Technology OSubsidence Control fH• I
Geothermal(Closed Loop) E)Tracer 20.DRII I:1NG LOG(attach additional sheets if necessary)' -- '
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft. To DESCRIPTION color,moron snivmckt � s m etc.
S �
4.Date Well(s)Completed: Well ID# R' ^^� R' Q, I n gnl D%AA. brow 11 S '
Sa.Well Location: S V.
Ar)sg I Q _urr►n ft. it.
Facility/OwncrName Facility TD#Cif applicable) D' M' k C e let "" k
1651 slam C,%Arrlr) -RA, OW-- ft. fL
Physical Address,City,and Zip % R.
21.REMARKS. ?rF>�.xac���
c3r rab V/11L Gt�IQl3;�G "iJr tR
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)dPermanent or OTempmrary Si&imM ofCcrtifi d Well Contracto Date
By signing this form.Thereby awify that the i ell(s)ivas 6vere)-constructed in accordance
7.Is this a repair to an existing well: DYes or-ONo Wth 15ANCAC 02C_0100 or IJA NCAC 02C.0200 Well Construction Standards and that a
Ifthis fs a repair,fdl out known well construction information and explain due natare of the cepl,ofthis record has been pravided to de well owner.
repair under#21 remarks section oron due back ofthisforat_
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 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
1- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: � (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd�fferenf(example-3@200'and 2@1005 construction to the following:
10.Static water level below top of casing. 310 (ff:) Division of Water Resources,Information Processing Unit,
Ifrvaterlevel is above casing,use-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LO (m.) 24b.Eor Iniection Wells: In addition to sending the form to the address in 24a
Al r Q Q}"�r`l above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: 1 I ` 1 construction to the foilowing.
(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
13a.Yield(gpm) Method of test: (5 A w c')`, 24c.For Water Suably&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
.}
13b.Disinfection type: 1 T Amount: I b, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016