GW1--04068_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
LL Well
Contractor Information::
&i``["k r 4z1 1 51-9. (Z.h S 0 11 14.WATERZONES
WcllCathsebrNaee " mot TO DESCRIPTION
ba ft. aQo ft. 1 GP1�'\
a4`i G a. ` '-kG IL 1-9- Cz F M
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(If e)
Stephensonts Well Drilling, Inc. FROM To DIMffiTER THICKNESS
, MATERIAL
Company Nome sJ fL r.,11`k ire Sbfp\al 1 \i
((��\ , I '1 �1 16.INNER CASING OR TUBING( at dosed-loop)
2.Well Construction Permit#: Cs W -- 1 !7l � 1 7 Q.O FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable of ll construction permits(Le.01C County.State,Variance.etc) Ai lA f f In.
3.Well Use(check well use): f ft. R'
}Water Supply Well: t ;I sCRE23t —
FRpM TO DIAMETER mars= TlIICIOIESS MATERIAL
Agricultural DMunicipal/Public N/A rt. IL In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. In.
Industrial/Commercial Residential Water Supply(shared) is GROUT
Irrigation FROM TO MATERIAL S` ' EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: V ft � }Q,lA QniT� ?o1M 11 soIb hc,9-t
Monitoring Residential
ft. IL ck;4,, ,
Injection Weil• u�"�
Aquifer Recharge DGroundwater Remedimioa
19.SANWIGRAVEL PACK j iplcable)
Aquifer Storage and Recovery QlSalinity Barrier To MATERIAL ESIPLACENEN'T117ETROD
RAquifer Test Q1Stormwater Drainage Z7A R.
Experimental Technology Osubsidesice Control ft. ft.
Geothermal(Closed Loop) DTracer-R 20.DRILLING LOG(attack additional sheets if necessary)
(Heating/Cooling Return) Other(explain under#21 Remarks) FROM amCR nox try hardness.salV cektype grate sus Cu.)
Q ft i R to - or
4.Date Well(s)Completed: - Ic\. a.Lk Well ID# I IL CI n' SG....14 cL.ik L 0kl
5a.Well Location: 1 1 ft- vL-k ft. S°1nc4 bC9b1TiN soli
C_.c\n�i ti1'... 1- mz-f •T r►r 1 V ce,,1" L t `-\. �`� E,`� NK.I.0 /
u�, ' ' `�! E�'
racilitylOamerNamc Baer' IDli(if applicable) rt. n:
ft ft. 1 V•+�r l..
6d L.- 1 �,ti t ur . Lr A�l�kt fore-it �s , ft. ft. JUL 1 2 2024
Physical Address,Coy,and Zip\„ ^�
..k 4z I 9�(JI^ r�l.f7 1/4.k S-Q,! I 21.REMARKS -614-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat1tong is sufficient) 22.Certification:
;\ ���1 ^'� , C� 1°\-aa
6.Is(are)the wells): Permanent or DTemporary Et__maiy�` fOettifi d1Well Contra. r Date
By signing this forma.I hereby certify°drat the uellt's),cur them)catzuracrer'in accordance
7.Is this a repair to an existing well: DYes or No with ISA NCAC OW.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill on:known well construction information esplanr the nature of the can'afth&record has been provided to theuell owner.
repair under#21 re.naris 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 l is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: $17$tt4IT3 A),INSTRUCTIONS
9.Total well depth below land surface: v ( ) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list all depths if-different(crumple-3Q200'ad 2®100) construction to the following
i0.Static water level below top of casing: 30 (f#.) Division of Water Resources,Information Processing Unit,
tinnier level is above casing.use--1-;„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Infection Wells: In addition to sending the form to the address in 24a
t� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r1,1 C�v �f construction to the following:
(Le.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) I - Method of test: v C>`UN e 24c.For Water Supply&Infection Wells: In addition to sending the form to
r 1 the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /I 1 Il Amount: I— I b 1 completion of well construction to the county health department of the county