GW1--06372_Well Construction - GW1_20241025

r
WELL CONSTRUCTION RECORD(GW 1) . For I vseOnl
L Well Contractor Information:
.-5�* r&\J \ . S I t,� t n •0 n H.wATERzorES r a .
Well Contemner N m •
PROM IL TO R DESCRIP11� •
.
cal a • A R R t 1
NC well conaaaorcettiflcnnoaNumber I.I.OUTER CASING Pr multi-cased wills)OR MEW )
Stephenson's Well Drilling, Inc. FROM To °I'METIM TillOCIORM MATERIAL
•
Camomie= CI R ., It: 1GI/1 in. SI)e. ;-t r V c
q� _ 16.INNER CATSOINGGOR (�omsCmaleland4aan)
2.Well Construction Pentad: N A _Lc f I�c ®n FRoa1 TO DIAMETER T M*TERLIt.
at all applicable nil construction ' (Le.WC Cowl%aft Varianaa etc) N/A It. f I ITM
3.Well Use(check well use): ft. .
Water8npplvWels t9.SCR>iCN
BROM TO DIAMETER SWTS1T8 THI RIS mama
,ggticultural DMonicipaYPnblic Water ��tt. It. In.Geother Geothermal(HeafinglCooliingSupply) ORcsidential Wat rSupply(ogle) A m R. I to-
Industrial/Commercial QjResidential Water Supply(shared) 18.mow
'Ration FROM TO DIATE IAL _I'2taLACEMENTAIETUOD.2AMOUNT
Non-Water Supply Webs •
. 0. it XQ f b Q,( QI;-L. 1'o tlr (o SO Ik1.-IRS`r
Monitoiin - DRecovcty . _tL it,_ Q /�.r
Infection elk R fk t
(pilfer Recharge DGronnclwaterRmudietion
19 SAND/G YSL PACK titau ble>'
Aquifer Storage and Recovery Eisalinity Barrier TO MAIERJM. PR &CEMEN MRTROD
Aquifer Tar QStormwater Drainage R it.
atimeatul Technology Control tt I•I. ,
Geothermal(Closed Loop) • DiTrucer • A DRILLING LOG(attaehadditlenstsheets ifneo r)
Geothermal afeatingcooling Return) .f OtherKaplan uds#21 Reraadts) FROBT To rioxcmlwtnm ,r.�nn.ztc .a„e*aeua
I . i I O Oi l
4.Date Well(s)Completed: \V—\--rx ol�well 1D# 0 - R (0 R' :-S" .,.N 1) v W� —i I .
a.WelLocatlons' 10 R .a%s$ � ` Shc t, r Q c K
`Q.A Aar\ Sr'S .r + _ _
Paciity/hveName Facility il(R cablc) R I. : a.- ,. d r
,; .
• 3103 t. dt rr p,A e-czarr.0a r N,C.... a:lrQa. it j. OCT z 2024
Physical Address.Crry,and Zip ft. I'
21.REAR 1,
G c.,,v Ile,
County
County, Parcel ldentifiaaionNo.(PIN)
Sb.Latitude and longitude in d /mtmutesfseconds or decimal dew
Ufa-ell Held,one latitongissufficient) • 22.Certlfcatlon: { -
.IC.' —1' aJ.i' N 1 3 1' as"' w i i
T . �-woe_'`' • 10- -,�.`k
�, .1. ;•�Well Contraeto�ir i%, Date
6.3s(are)the well(s)Q1PermaneIt or Temporary . "' .
- - Ity atatag adrjotra.Ilax*ee>t&that the ualgsllawr(tan)cod em ed la aadaace
7.1s tLit arepalr to an existing well:
yes or [/No with Mimic O2C.0100 ar lid NCAC(12C.4209 Well COnstrumion Standardeoaddmt a
fad ctvarepakfal ant lama welIcetnuufUaahjaaratien and made ate=weoftha con'ojthiatemrd has hew ptovM edtothenaaoxner.
,elratrrauherH2l reMorisseettan area the back gfr6tsjarar 23.Site diagram or additional well detail=
8.For GeoprobelDPT or nosed-Loop Geothermal Wells having the same You may use the back of this page to provide adrfit mel well site details or well
construction,only I G I is needed. Indicate ofwells . COnstruetioadetails- Yonmay
W also attach additional pggeS ifne euaury.
drilled: -I- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . 9J (a) 24a.For All Wean: submit this farm within 30 days of completion of well
For twill&!ervelLslist ail depths ifd t(ammple-3(422000�.gad30100') eonstmcdonto the£ollowing: ,,
• is Staticwater level below top of casing: tj V (ft.) Division of Water1Resonrces,Information Processing Unit;
!lively.level&above castnw we+C 1617 Mail Service Center,Rateigh,NC Z7699-1617
IL Borehole diameter: ' (in.) 24b.goriniectfon Wells: In addition to sending the form to the address in 24a
p- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:-- r 1, �b.,'\, construcdonto the following: 1
(La auger,rotary,cable.dkcet pleb,etc)
Divisionof Water Resources,Underground Injection Control Program,
'FOR WATERSUPPL(Y�W►ELLS ONLY: 1636 Mil Service Center,Rateigb,NC 276994636
13a.Yield(gpm) v Method of test: CkA 3 Z 24e.For Water Sagnly&+Tallmaarr Wells: In addition to sending the form to
the address(2) above. sled submit one copy of this farm within 30 days of
13b.Disinfection type: p 1 i T !u 1 Amount: 1 lb completion of well constmetIcn to the county health department of the county
when constructed. i,
a....r:w--1 Noels Carolina Decrement of Oaality-Division ofWatetRtaotucts Revised 2-22-2016