_Well Construction - GW1_20230310 (41)

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
1.Well Contractor Information:
1 14.tYATERZANES
Well Contractor Na re FR�O,.MR TO DESCRIP11
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mNti-cased wells.OR LINER ff ROD livable)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATEHAL
Q) ft. SS ft 6ll in. Ste,a
Company Name 16.INNER CASING OR TUBING(eothermal closed4ou
2.Well Construction Permit#: ���,3-J FROM I To I DiAMMIL THICOMS I MATERIAL
List all applicable well construction permits(La WiC,Count}:Statue Variance,eta.) Aft• % m.
3.Well Use(checkwell use):
17.SCREEN.
Water Supply WeU: FRODI TO I DLIMETER SLOTSIZE TffiCKhESs MATERIAL
Agricultural OMunicipalftblic tt. ft. in.
Geothermal(Hcating/Cooling Supply) 01I sidential Water Supply(single) ft, in
HIndustriaUCommercial DResidential Water Supply(shared) 18.GROUT 1
IrriRation FROM TO MATERIAL. EIYTPLACE KENTMEfHOD&AruouNT
Non-Water Supply Well: ft' aQ 'L 50 ib f>\
DMonitoring- DReeovery ft. ft Cl�l
Injection Well: ft tZ
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK rf a licable)
Aquifer Storage and Recovery Q1Salinity Barrier FRo TO MATERML BMPLACEI1i N METHOD
D Aquifer Test Dstormwater Drainage ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRIL.1:lNG LOG attach additional sheets if necessary)'
Geothermal(Heating/CoolingReturn) nOther( lain under#21 Remarks) 1
FROM I TO DESCRWrION color,hardness,sotUrock e. -et<
ft.
► ft- 0 r '
4.Date Well(s)Completed: �3 Well ID# ft' 10 ft. EA SC.n(7l C 0�
Sa.Well Location:
�
Facility/Owner Name Facility ID#(if applicable)
?��61 if , 0Q r �k 0.�Ce��or2r alSC� ft. n MAR 7 2023
Physical Address,City,T Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees:
(if well field,one lat/long is sufficient) p, 22.Certification:
N � DO 35" I I W
k n
6.ls(am)thew Permaneut or Temporary Signand oWrtificdVell Contractor Date
By signing this form.I hereby certify that the wells)was(vere)constructed in accordance
7.Is this a repair to an existing well: [3Yes orlZfNo ulth ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copj,oft his record has been provided to the well owmer.
repair under#21 remarks section or on 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: :1 SUBmnTAL INSTRUCTIONS
9.Total well depth below land surface: 3� ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a!1 depths ijdifferent(example 3Q200'and 2QlOD� construction to the fbllowi�g:
I&Static water level below top of casing. (ft) Division of Water Resources,Information Processing Unit,
Ijwaterlevel is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: C P10�Fr construction to the following:
(ie.auger,rotary,cable,direapasb,ete.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: Go&Cg. 24e.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also'submit one copy of this form within 30 days of
13b.Disinfection type: Amounts 16,, completion of well construction to the county health department of the county
where constructed i
IT..—nW--1 North Carolina Department of Snviromaentai Quality-Division of WaterlResources Revised 2 22 2016