GW1--05666_Well Construction - GW1_20240920

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WE,CONSTRUCTION RECORD(GW 1) For Internal Use Only: ,
L Well Contractor lnformation:
—5-e—iLC -2\I I ;Sk-Ql* AQ./rf•O n 14.WATIIR.ZON&S
WJlControcterNime FROM TO DESCRIPTION
a04 tL: Q�Q•IL q CspM
NC Well Contractor Certification Number 15 OUTER CASING(fornol8•eesedwells)OR LINER Of )
Stephenson's Well Drilling, Inc. FROM TO DI*MET= , MUCHNESS MAT
Company Manse ft. 5 IL , 6i"a• spN al ?NI i
1cnip cats laGon G(mothermdelosed-Isso)
2.Well Construction Permit: �� 1ritOM TO DIAMETER THICIQ� _ tHAT&RtAL
Litt ail applicable nail aannhucdanp orn&(Le:WC,Cow4i.State.Varimux etc). /,A fT• It 1, ! la
3.Well Use(cheek well use): n I. in.r.
Water Supply Well: bgo� DIAMETER SLOYS== THICiO DIS MATERIAL
Aadcultival At/Alt IL l! In.
Geothermal(HcatinglCoolinl Supply) 74!Residential Water Supply(sin o) n it,, Ira.
IndusteiallCommcrciel it• '- WaterSuppiy(sbared) la atom i,
Irrigation . PROM TO MATERIAL {fet +C (TM!1UODDASIOONT
Non-Water Supply Welk Q ft. aQ le,1421�it [ 04( IQ co(b iutp'
m»toring - -- ['Recovery-- --- --- .- - ti: St. C h}e t -
injection Well: rr� ft. -
uifa I�
Recharge CuoundwaterRemediatiw 19 SAND/GRAVELPACKKO mIP1Icable)•
_ Aquifn.Storage and Recovery . DSalinity Barrier -. f TO MATEMAL EMPLACEMENT'METHOD •
Aquifer Test C11StormwaterDrainage ' /A ft.
erimentalTechnology DSnbsidrnoeControl ' ' M ft. ft. -'
Geothermal(Closed Loop) DTracer - 20.DRILLING LOG(snob adrift d se tsMammary)
Geothermal aleating/Cooling Return) r)Other(explain under#21 Rotundas) e� TO r taaamr.:ann.etR ante:sea ems)
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4.Date Well(s)Completed: ao �"� Well IDP — I tt. I 0 fz Bengt l r�l G I NV
Sa.Wen Location: 1 6 n' 5-C) f 'So*j bro lc r r 4 C K
` -o.cc b Tkc,l�o.J'.rOi. 510 ac ft. To c.' :1 — v f.7
Facility/OamcrName Facility m#(ifappticablc) - f It. •---. •i i,:
Q.°\ Thor. sun \rJO' 1 C➢` ftrd a-‘ SE5' ft. ft. St!' C 0 ZOZ4
• Physical Addtess.CuY.and Zip Cy •, Ir,{�:'P'u:t's•a'?r. �ve�-.�i tear
rN AV'',It) l����9��.5a. J 3 21.REQMARIIS Nfl:r a.0:-
County Pascal ldeatilcoionNo(PIN)
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5b.Latitude and longitude in degrees/minutes/secends or decimal degrees: ,
awed field,ono ladlongis sufficient) 2 �^•l G 22.Cron: I jd a�j �! " N ��° J I / d� 0 'l W ,} �-, AAA �rm�o�a,^ 0 o��
&Ifs(are)the wel(s),Permanent or - 1i' Wdl Coatrae Due
By sntaa this forts.I hereby sere time the ndf(s)was(we)rnnstrruted is accedence
7.Is this a repair toandwelt QYes or 474No with1JANCACO2C.0100arIfANCACMC.OZUOWellCoafrualonSimila►draadtheta
. OihtrLsa mar.jilt out knownwelIa lanisfennationarulapls&thenatrreofthe colaNfhirremedkm been ptovFdrti►otrew&owner-
rrpaktuutert2l remadessectimt neon the backtithtsfamc 23.sllte diagram or additional well detntls:
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
"emotion details-You"'also each additional pages ifnecesmcy.
consttuctiogonly 1(tWl l is needed. lndita+leTOTALN(JiuID}sRofwells a ; I
R7 O NS
9.Totalwelld�thbeknvlandsur " � � 1) 24a.For Al Wells: Subrntj this farm within 30 days of completion of well
Fbrmai*wells l sta,Ide the rdlmant(a 8®IQO end2600)- e on to the following
10.Statism:aer level below top of casing: a (ft) Division of Water Resources,7nfbrmation Processing Unit,
!finger level fs above easing.we+- 1617 Mail geeviee Center,Raleigh,NC 27699-1617
11.Borehole diameters (m.) 241),For infection Went 'In!addition to sending the form to the address in 24a
12.Well construction method: t �-�0 0.f above,also submit one copy of this form within 30 days of completion of well
(Le:auger,ronuy,cable.ditectpusb,etc.) CtlnsnataiDn>b die following
Division of Water Resources,Underground Injection Control Program,
FOR WATERSUYPLY WELLS ONLY: 1636 Malt Seivlce Center,lalelgb,NC 27699-1636
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13a.Yield(gpm) I+ Method of test c3ONSYs 24c.For Water Sunaly&jnteetlon Wells: In addition to sending the fame to
_ {� { the adti (es) above;, also submit one copy of this form within 30 days of
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13b.Disinfection type: 1� 1 t 1 Amount .1- 16 i ' completion of wall conguiction to the county health department of the county
when conslucted. ,
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P,mnfW-t North CemiinaDeo eanent of Envinenneniel Marne-Division of WaterlesTie= Revised 2-22-2016