_Well Construction - GW1_20230320 (70)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: -I
Je ff r �t S4-e-r1 e.rVifir. 14.WATERZONFS {
Well Contractor Naa FROM TO DESCRIPTION
act ft. QC\4 ft 1— G P M
D-L - '. A Ltao ft- Liao it- 4 c.TP/h
NC Well Contractor Certification Number 15.OUTER CASING(for molti=eased wells)OR LINER(if ap licable) -..
Stephenson's Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. —t(� ft. fi� in. S bp' al I V
Company Name �[ ^� 16.INNER CASING OR TUBING(geothermal closed-loop]
2.Well Construction Permit#: .\ O'*� c.. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.[TIC.County.State.Variance,etc.) 1✓14 ft. ft. in.
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public A/A ft ft. in.
Geothermal(Heating/Cooling Supply) 0-Residential Water Supply(single) ft. it In.
Industrial/Commercial °Residential Water Supply(shared)
pp y FROM GROUT
I
Irrigation TO MATERIAL _ EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well:
ft' O ft- 13�n`to, k Pow- II �0 h bG1 SJ
Monitoring °Recovery ft ft. C ! r v
Injection Well: ft.
f Aquifer Recharge
tt, ("'
Groundwater Remediation
19_SAND/GRAVEL PACK'(if applicable) :
Aquifer Storage and Recovery °Salinity Barrier • FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ft-
Experimental Technology QlStormwater Drainage
°Subsidence Control a ft. it
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness swL.aek type grain )
Qft. / It ! Orro; 1
4.Date Well(s)Completed:3_,_a2, Well ID# / it• Q..g"ft. Ne.(k c JrJ1y
Sa.Well Location: S'ft 13 ft [firO k+1!1 ssA/1(k
Cro‘nt"i.e., e, Ho rne,s,S \e.crovN s`t'ates Lot 4- 13 ft. it`#Sft. 9k14 _
Facility/Owner-Name Facility ID#(if applicable) ft ft' s [[_.• .t r�""'ILL^,+,
..„. n S� 4 la tf 0 /
3°10Lf Lotv►rjj CreeK 1-.A,, , It,�c.kt,Fore..s1"ais17 ft ft p 0 �{j
3
PhyysiccalAddress,City,and Zip (� ft. ft. IV� ` L�+�
V rAhV/Ile, I%a�ta�``�13^3 J .21.REMARKS. . `,-,.~a r 73- : -.-.5 Ur..
D X Qi•iOL7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1 �/ 22.Certification:3Q° 3 ' . %a N —1% �� 4S W kvI1, , T, 3-1 -a3
�,( eat or OTemporary Siv,r o &Bed CHContractar� l Date
6.Is(are)tbewell(s) ZlPerman ° mp racy
```V���� By signing this form.I hereby certify that the well(s)ins(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or ONo with 15A NCAC 02C_0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fdl out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
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-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 4.. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: LF 4 J (ft 24a. For All Wells: Submit this form within 30 days of completion of well
For nutltipie wells list all depths ifdifferent(example-3Q200'and 2ta3100) construction to the following:
10.Static water level below top of casing: $0 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"}" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: E (m) 24b.for Injection Wells: In addition to sending the form to the address in 24a
Y above,also submit one copy of this form within 30 days of completion of well
12.Well p construction method: ,/ [t r Rof R construction to the following
(ie.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) vY Method of test &CkU se, 24c.For Water Supply&Injection Wells: In addition to sending the form to
H the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I1 T Amount -1-- I b. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of WateriRessmuces Revised 2 22 2016