GW1--03091_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
L ll W& Contractor Information:
-
;---Q. T-p c' i T 1 eANs on I4.WATERZONES
Well Contractor Name"` �S' i 1 FROM TO DESCRIPTION
; Lt4D\ a` eft. ayG It. iQ GP,\
fL ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of e)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER 'THICKNESS MATERIAL ,
Company Name 4 �(,C� 0 ff. C f11. v I/K tillDP.D ) P V C.,O 3 ll 16.INNER CASING OR TUBING(geothermal closed-loop)2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County.State.Variance etc.) A//A ft.
ft. in.
3.Well Use(check well use): ft. R
Water Supply Well: 11'SCREEN
FROM TO
N
Agricultural DMunicipal/Public /� ft
DIAMETER SLOT SIZE THICKNESS MATERIAL
In
Geothermal(Hcating/Cao{ing Supply) Residential Water Supply(single) / In. '
Industrial/Commercial Residential Water Supply(shared) I8 GROUT
flln'igation FROM TO MATERIAL E IF ACEMEFtTMEiHOD&AMOU T
Cron-Water Supply Well: 0 it 0,0 ft. IS-emio,life F()U r 10 Sol6 ID(nqx
0Monitoiing QRccovcry ft It
Injection Well: 1 ft. Ira CjPJ
3Aquifer Recharge (jGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ❑Salinity Barrier Fnw TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage // 4 ft' ft:
3 Experimental Technology DSnbsidence Control ft. ft.Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheds if necessary)
)Geothermal(Heating/Cooling Return) (Other(explain under all Remarks) i FROMso DESCRIPTION(rato�twaa�w��r�rlcty� �a ettl
Q ft. / ft Tor -co i 1
4.Date Well(s)Completed: --'I ,a` Well ID. + / n' 0.0 n. 1510 t n -)A/1i.Ly -TO;
5a.Well Location: �a� R. 'N1 it. ..3
crc\ 1'\ f 4C)tr �.1- 1"i cars N)lot, AC re.t- Lot !Q I �1 ft. t '' ,- oc <<
Facility crName Facility tOe(ifappficablc) ft. rt.
%_� -....,
lac Li',irc‘re. LtNnQ. �0�11 +nr '5 ,C. .a i.S-V1 ft. frft. ft. MAY 2 `t., (C"l_4
Physical Address,City,and Zip
�..-- 21.REMARKS
Fr��.rk ;r ,AN
County Parcel Identification No.(PIN) J:i.. -.;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/iong is sufficient) 22.Certification:
36 r r N -Vic
° IS"' 3t r 5" aLk
6.Is are the weIl s Permanent or Temporary Si Wall Coarser Dam
By signing this form,I hereby certify Thar the nell(s)tau(were)constructed in accordance
7.1s this a repair to an existing well: nYes or o with IRA NCAC 02C.0100 or ISM:NCAC 02C.02011 Well Construction Standards and that a
If this is a repair,fill nut known well construction information and explain the nature of die eon'ofthis record has been provided to the well owner.
repair under 421 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: I
( l SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v J IR) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths ijdJerent(example-3(200'and 2@100') construction to the following:
10.Static water level below top of casing:g' 3v (h) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C CIO 24b.For Injection Wells: In addition to sending the form to the address in 24a
A 1 !(-
12.Well construction method: / t tf y above,also submit one copy of this form within 30 days of completion of well
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 Mali Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I 0 Method of test: \S O` y 24c.For Water Supply&I:nlection 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: N T 1 Amount lb. completion of well construction to the county health department of the county