GW1-2022-10383_Well Construction - GW1_20221115

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
i.Well Contractor Information:
75'-, r cq I la.wAT7 xzoNEs
Well Contractor Nade 1 FROM To I DESCRWnON
�® ft. U ". 1 M
_ 01A P� fL ft.
NC Well Contractor Certification Number IS OUTER CASING for mtilti-civsed wells OR LINER tf a IIcable) --
Stephenson's Well Drilling, Inc. FROM To nrAnl>reR TmcxNEss MATERIAL
ft. I a4 ft. r in. SDN aI G
Company Name 16.IlVNER CASING OR T[1B1PtC euthermal closed-lo"
2.Well Construction Permit#: I FROM I To DL>NIETER THIC[QHFSS MATERIAL
List all applicable well construction permits rLe.UIC,County:State Variance,eta) A11A ft-
ft- la
3_Well Use(check well use): D' I tZ in.
Water Supply Well; 17.SCitEEN..
FRObf tlL
DIAMETER SLOT SIZE TMCI NTT MATERIAL
PAgricultural [3Municipal/Public fL 1 . SCh
Geothermal(Heating/Cooling Supply) oRcsidential Water Supply(single) ft. la •
f Industrial/Commercial OResidential Water Supply(shared) •.18.GROUT_
Irri lion
FROM TO MATERIAL EMPLACEMENTDIMOD&A1IIOUNT
Non-Water Supply Well: Q D' Q ft a2.1. Pour .Sob -r
- i= Monitoring ,-Recovery fL ft J
Injection Well: ft. fL
Aquifer Recharge oGroundwaterRemediation -..
19=SAND/GRAVEL PACK tf a livable
Aquifer Storage and Recovery [3SalinityBarrier FROM TO MATERIAL EMPLACEMM17hMTROD
Aquifer Test OStormwater Drainage AIIA D' n
Experimental Technology [3Surbsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRUJANG LOG attach additional sheets if nee
r-lGeothermal(Heating/Cooling Return) 00ther(,explaintinderf2l Remarks) sROM TO DFSCRWnON color.da.decss.sawrock ty gruin S"etc.
4.Date Well(s)Completed: oC� Well ID# D' ft' C A
Sa.Well Location: D' g SG sS C
i f It. ft.
ry
Facility/OwncrName Facility M9(ifapplicablc)
ft. fG c
�-5,10 Munns FA, Crime tnnr N'k. xls'aa
Physical Address.City,and Zip ' ft. NOV 1 v :U2 L
Q'(-0,h V t���/ 21:REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fatitong is sufficient) 22.Certification:
6.Is(are)the wells)#! Permanent or Temporary Si o Cctti ed Well Contract Date
�T By signing this form.I hereby certify that rite inell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or ON- uIth 15A NCAC 02C.0100 or ISA NCQC 02C.0200 Well Construction Standards and that a
Ifiltis is a repair,flit out known welt construction information and explain life nature ofrhe copy ofthis record has been provided to the urll owner.
repair under 021 remarks section or an the back of thisform.
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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
dried: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3�'I (-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 010erent(example-3Qa 200'a(ndd 2@100) construction to the following:
10.Static water level below top of casing: 3 V� M) Division of Water Resources,Information Processing Unit,
Ifrvaterlevel is above casing use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (m) 24b.For Infection Wells: In addition to sending the form to the address in 24a
(2� above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: 1 11Q�(i\f U construction to the following:
(Le.auger,rotaM cable,direct pusb,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) 1 --X Method of test: ��C1..�AQ� 24c.For Water Supply&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: Tit M Amount: �b. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carotin Department of Envhonmental Quality-Division of Water Resources Revised 2-n 2016