GW1--04970_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
e. A.-«\I 1 Vke-�3(\e_r J'0 l'1 =14.WATER ZONES i
Weil Contractor N FROM TO DESCRIPTION
��a.' . k a�Lk�ft a4 Q ft. I uM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Cif a livable).
t FROM TO DIAMETER TIDCKNESS MATERIAL
Stephenson's Well Drilling, Inc. �1 _ 1� p
Company Name ft oi� ft i/ in S W +N at 1 \C
�� �� 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FRO TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Count;State,Variance,eta) iv A f. It. in.
3.Well Use(check well use): ft. in.
I Water Supply Well: FROM
F SC1tEEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public Q ft �t• c C� lft� �Q..
OJ�ft L I, m � �(�
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single) it ft in.
Industrial/Commercial QlResidential Water Supply(shared) 18.GROUT
nirrlgation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: (3 ft a0 ft- P'tdoh1'c ib b Four I® Se, oss
r- Monitoring - DRc cowry R. ft �' �iD.1
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QISaI'mity Barrier FROM To MATERIAL EMPLACEMENT METHOD
i Aquifer Test IStormwaterDrainage 0 ft. �j�ft' SAh�ft. Vc u r
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRII:LINGT LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sontroek type.gsaia sire,eta)
0 ft. 1 ft. 'Me s0 i 1
4.Date Well(s)Completed: - --1'O3 Well ID# ift' I' ft' r.('Q /J 1'1 SO t I
5a.Well Location: 1 S ft' erf -5 hcA ro^c.1k
POC ri C-i c E►t'o ry ft. tt. p � ., ....,, ...:_'
Facility/OwncrName Facility ID#(if applicable)
Usk-I C.Qsl. P4. Creek our N.c.. aisaa ft. ft. AUG 0 7 2023
Physical Address,City,and Zip ft. ft. Itriv.--nn',s'n_?ram ,^'+..,3 Ur
CT rtrnv t 11.E
21.REMARKS pay. 3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
_�'' Lt � )1 N -kV' LAD.' S-0 w �-Ii - 3
6.Is(are)the wells) Permanent or.[Temporary
Si Certi Well Contras � Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: f Ycs or TAN. with 15ANCAC 02C_0100 or 1SA NCAC 02C.0100 Well Construction Standards and that a
Phis is a repair,fill out known well construction information and explain the nature ofthe copy alibis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3@200'and 2Q100') construction to the following:!
10.Static water level below top of casing: SA c) (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: . . ( i.) 24b.);or 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: rl I r I N0 Al ; construction to the following:,
(i.e.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; CYRVi 3 gs 24c.For Water Supply&Injection 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: I-1TH Amount , completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of WaterResources Revised 2 22 2016