GW1--04847_Well Construction - GW1_20240814

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WELL CONSTRUCTION RECORD(GW-I) Far Internal Use Only.
I-Well Contractor Information:
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1vcllcouEiadorl FROM TO DE CRIPTION
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NC Well Contractor Certification Number 15.OUTER CASING(for multi-mad MVO OR MLR Ora#t t ei
Stephenson% Well Drilling, Inc. FROAf i To r DIAI i TErt agEss tMATERIAL
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Company Name (� p� 16.INNER CASING OR T
a`1 \ (3BIPA�( rmai closetWoats)
2.Well Construction Permit N: FROM , TO DIAMETER. THICKNESS RIA.TrSBIAI.
List all applicable well construction permits(Le WC.County.State Variance.etc) - �Aft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: 11.SCREStiI
Agricultural a:Municipal/Public tL ft. DIAMETER SI.GTS*.ZE T!$cz msS MATF.RTAL
Geothermal(Heating/Cooling Supply) tree•tsidential Water Supply(single) `�/`/1
Industrial/Commercial DResidential Water Supply(shared) R.
IS.GRGROUTTO
it. la
b.
Irrigation FROM ' TO ' MATERIAL !E
rmAC r rommoD&AMOO?4 T_
on-Water Supply Weil: U �j f %�StL i f_o u r I�1 S ) l b bJ
f1Monitoring []Recovery ft. ft Ghjer
l injection Well:
JAquifer Recharge jGroundwaterRemediation
19.SAND/GRAVEL PACK makable
DAquifer Storage and Recovery J1Salinity Barrier t TO MATERIAL I EMPLACEMEATMETEIOD
nAquifer Test QStotmFater Drainage ft. ft.
tExperimentat Technology OSubsidetice Control 111 ft
Geothermal(Closed Loop) FirrIsIceT 20.DRILLING LOG(attarh add sheets If nee nix)
Geothermal(Heating/Cooling Return) Q0ther(explain under#21 Remarks) FROM TO DESCRIPTION( sa�trezictyoe main ni ci )
l G ft. I ft. IoronI
4.Date Well(s)Completed:1- 1 a� Well II# 1 O' ( ft- .QtWyr• J-d 1 1
Se.Well Location; 1 S a' 5 5 rt. SQ 1.1 c 0 c K
C \\ ,3-(')1.1 s ih 3aS$ 4Cx
Facility/OwnerN Facility tDd(if applicable) D' ¢
Physical Address.City,and Zip . It. ' a,,,4 '
Cscarw.1\\t �0\iooCLt13'-t `',\ IL REMARKS _ ,
County Parcel Identification No.(PIN) 1
Sb.Latitude and longitude in degrees/minutes/Seconds or decimal degrees: I l;vz;.t•3Li J f
(if well field,one Int/long is sufficient) 22.Certification:
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6.Is(are)the wel(s) Permanent or DTenmorary _ tutu Coacae Date
•/ By signing this fora.I hereby tort fy that the nall(s)war(once)rnrtstructal in accordance
7.1s this a repair to an existing well: DYYes or.i2iRo with ISA NCAC DX_0100 or ISA IVCAC 02C J3200 Well Construction Standards and that a
illsis a repair.fill narkrona well construction information and explain the moire ofthe copyoflhis nears'has been provided to the well owner.
repair under m2i remarks section Oran the bock of thisfarra.
Site dingrattt or additional well detssits:
o For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site detnit5 or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: •• SUBMITTAL INSTRUC IC 's_
9.Total well depth below land surface: a•� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple nneilr list all depths if (erent(eromple-3@Z00'and 2®100) construction to the fallowinu
10.Static water level below top of easing: 3o (it) Division of Water Resources,Information Processing Unit,
If salter level is abate casing,use'+'c 16I7 Mail Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 24h.for Inleetion Wells: in addition to sending the form to the address in 24a
12.Well construction method: Air
/� �a l{ above,also submit one copy of this form within 30 days of completion of wwell� f�/ construction to the following
(Le.auger,rotary,cable,direct push,ern.)
DivLeionof Water Resaareas,Underground Injection Confrol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Masi Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) ,D V Method of test CTC>t Y‹ 24c.For Water Supply&Injection Wells: in addition to sending the form to
l ( the ad (es) above. also submit one copy of this form within 30 days of
i Al.Dicinfection type: ` \ 1� Amount 1— I b• completion of well construction to the county health deparoneat of the county