GW1--03327_Well Construction - GW1_20240603

IONIMMONIONMENT
WELL CONSTRUCTION RECORD(GW--11 For Internal Use Only.
1.Well Contractor Information:( r I
Se.- V c(� 'T . SA-t.r e.n J Q 14.WATERZONS3
Well Cont+actorer FROMt TO DESCRIPIION
Naw
aox R aO0 It S G PM
a`-t a.'l I\ a-55'ft• ;3°,n .\ G r,M
NC Well Contractor Certification Number IS.OUTER CASING(for molt}cased wells)OR LINER(if )
Stephenson's Welt Drilling, Inc. FROM TO D r C MATTERVIL
Company Name Q ft. 1 ft E�I knr. 2 t)r• D,' [ 4 C.
�� TO 16.INNER CASING OR TIMING(�thermd doxd-loop)
2.Well Construction Permit#: v pR DIAMETER THICKNESS MATERIAL
(ie
List all applicable well construction permits WC County State Variance etc) 17 1. It ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 1 Pt-SCREEN
FROM TO
Agricultural 6MmsicipallPoblic ]�It rt. D1MtICIER S10PSIZE THICKNSS MATERIAL
(Heating/Cooling Supply) Residential Water Supply(single) / is
t.
industtial/Commerciat QiResidential Water Supply(shared) jg,GROUT
nl ltrigation FROM To MATE3IAL _EMPLACEMENT METHOD&AMOUNT
[on-Water Supply Well: O ft. aO $ g+Z,n' f itt,?a 11s c1 S Q(b } Ay
Monitoring DRecovety ft It KIP J
Injection Well: ft. ft.
Aquifer Recharge jGroundwater Remediation
19.SANDIGRAVEL PACK lid applicable)
plAquifier Storage and Recovery QiSalinity Barrier FRONT TO MATERIAL EMPLACEMENT ME FIOD
jAquifer Test jStormwater Drainage d f} R. ft.
Experimental Technology jSubsidence Control ft ft
Geothermal(Closed Loop) jTracer 20.DRiLLING LOG(antra addltiaeal sheetsIf necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) � To d etc.)R � IopJo:1 /
4.Date Well(s)Completed:S a%-a%•-\Well III ___, ft. -t a a ft- I _N Qi scx ncni/ Cio
5a.Well Location: V fi Ig- " Jan v1
<� livr,e kv,-J4Qr,to AN,.r --,^ ,,., ALrzJ 1 -) a 1.1 ft, a4 5"f i oiLk
Facility/Owner Name Facility Mil(if applicable) j ft. ft.
D\U Le, 0rt Las Lo `I cv-_ N,Q, a i S i 0\ j i
Physical Address,City,and Zip ft. ft.
Frtv n k tv, Zi.REMARKS .o. .iii-I of
County Parcel ideatifr+ation No.(PIN)
5b.Latitude and longitude in dynes/minutes/seconds or decimal degrees:
(if well field,one!at/long is sufficient) 22.Certification:
/ 3 ti N --Ate 15-1 t1‘2J , ` +1I ) _ C-aci-a�
Ten Si S I Well Contras r Date
6.Is(are)the wells) 1Perm_arwent or Porar=r
V ,.'sy signing this faros I hereby ce tifr that the as/l(s)sour(were)constructed in accordance
7.Is this a repair to an existing well: lYes or\dNo with ISA NCAC OW.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
phis is a repair.fill out known athl constnz tion information and explain the nature of the 03M'ofihir record lies been provided to theneil owner_
repair under#21 remarks section or on the back of thrsfamh_
3.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 she 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: 1-.. SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wets list all depths ifdffereitt(example-3@MS'and-VIM construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If enter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
:1.Borehole diameter: (.3 em.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
D. I r n\QtC^r y above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: I \ construction to the following:
(Le.auger,rotary,cable,direct purl,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) I a Method of test \1-O`ill 3 t 24c.For Water Snooty&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: h I /7 Amount 1 /b i completion of well construction to the county health department of the county
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