GW1-2021-00942_Well Construction - GW1_20210401

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well ccContractor Information: Lt
�12"CT�Q.�I &iQD11Q.t1-J'0 r\ 14.WATERZONFS
Well Contractors Alante MoM S ft ft.�- TO DEscKirnori
.
a'a- A aas IL �a,s ". I i 5 G P M
NC%bell Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf lleable
Stephenson's Well Drilling, Inc. FROM Tt�� t- D Tffi MAIL
CompanyNnme p� ® � `J � �1� 'm So� &l v V
2.Well Construction Permit#: ��� \ FROM6. NERCASINGORTUB AM tbermatclICK too
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable=11 wnstraaion permits(r.e.II1C Coanl:State,Yariance.etc) �'
3.Well Use(checkwell use): ft'
Water supply well: 17.SCREEN
FROM TO I DIAMETER I SLOTSI78 I THICraTSS I MATERIAL
Agricultural DMunicipaMblic ti ft. I ,}d
Geothermal(Heating/Cooling Supply) -.Residential Water Supply(single)
Industrial/Commercial DResidentiai Water Supply(shared) 18.GROUT
I—IhTigation FROM TO MATERIAL EMPLACE UNT METHOD&AhiouNr
Non-Water Supply Well: ft- a 5t4pt,3 C S 1b A
Monitoring Rccovcry M tL
=Rechaw
Well: ft. fi:Daroundwater Remediation
19 SANDIGRAVEL PACK a tcable
Aquifer Storage and Recovery Oi$aunity Barrier FROM TO I MATERIAL I EMPLACEME1%"rMSMo1)
Aquifer Test DStormwater Drainage
Experimental Technology OSubsidence Control % 1L
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets ifn
Geothermal(Heating/Cooling Return) - Other(explain under#2I Remadm) FROM I TO DFSCtaITIOw color,hnnhw s,sdUrecktypy,wain am ate.
ft. R. Cko -
4.Date Wells)Completed: -°�'2( Well ID# ft- 3 ft L64
5a.Well Location: 30 ft. C\® IL s
ZL C, D\0 ft: a`t s R
Facility/OamcrName Facility ID#(ifappiicablc)
iL
4 s,w A rkl�—,vL—�(i e x„1 Lt\. Lot C13 �x&A,2-1 6 5 ft
Physical Address,City,ane Zip ft. ft. `" Y�
Cr r� anv:I It 101 i1.R>rn�IAlucs
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: WWI
(if well field,one lat/lang is sufficient) 22.Certification: (i if vil I a{VV R�i£^.Y r S i'O
p" '011
3ro° J mot' I" N _ � 31 ,lj W
t
6.Is(are)the well(s)OPermanent or nTempormy Siskdftu6bYCcrfificd well can r Date
By signing this form.I hereby ceM6,flat the nvg(s)wu(were)cote nwied in accordance
7.Is this a repair to an existing well: [DYes or ONO with 13A NCAC 0-11C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
ydds is a repair,fdl out known well consauction information and explain the nature of the cM,ofthis record has been provided to the well onTter
repair under#21 remarlasection or on die back ofthisform.
23.Site diagram or additional well details•.
You may use the back of this page to provide additional well site details or well
&For Geoprobe/DPT or Closed-Loop,Geothermal Welts having the same ,
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed- SE AL INSTRUCTIONS
9.Total well depth below land surface: 4 S ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdfferent(c=ple-3Q200'and 2 aQ1009 construction to the following:
10.Static water level below top of easing: (M) Division of Water Resources,
Ifivater level is above easing.use+" Information Processing Unit,
16I7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. , 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /� r( �0 1 AP�I abovq also submit one copy f this form within 30 days of Completion of well
(i.e.auger,rotary,cable,direct push,etc.)
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Prograrn,
1636 Mail Service Center,Ralelgb,NC 27699-1636
13a.Yield(gpm) V Method of test: 24c.For 1'Vater Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form anthin 30 days of
13b.Disinfection type: Amount: 1 b• completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Ouality-Division of WaterResourees Revised 2-22 2016

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1�Well Contractor Information:
�1��'TC'Q\)��(� ���e•� !'01� MWATERZONES
Well Contractor Nanle FROM TO DESCREMON
ft 57
NC lb'elI Contractor Certification Number 15.OUTER CASING fibir znW"tsed wells OR LINER Cif lit�ble)
Stephenson's Well Drilling, Inc. FROM TO DIAM MR TMC�Fss!'JMATERi4L
Company Name _l
it. Q, ft, Q1 �n SQ(2\ al VC
3 A Q `� 16.INNER CASING OR TUBING eothermat dosed-too
2.Well Construction Permit#: Q \ FROM To I DMAIRS TMCKNESS MATERIAL
List all applicable ivell consimcdanpermits f e.M.Coun(;State,Variance.etc) fLfL m
3.Well Use(check well use): Alt A fL fL 'n-
water supply Well: 17.SCREEN
FROM TO DIAME[ER 1SLOT SITE THICKNESS MATERIAL
Agricultural OMtmicipai/Pubiic M g. in.
Geothermal(Hcating/Cooling Supply) 42fResidential Water Supply(single) M ti, hL
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT ,
.� hTleation FROM TO MATERIAL EMPLACEMENT METHOD&MOONT
Non-Water Supply Well: ft• a & ell\ 0 Ur a
Monitoring 011ocovery ft. M Ci
Injection Well:
ff.Aquifer Recharge Groundwater Remediation ft.
19.SAND/GRAVEL PACK rf a ticable
Aquifer Storage and Recovery OSalmityBarrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test QlStormwater Drainage VIAtt-
Experimental Technology Dsubsidence control IR ft.
Geothermal(Closed Loop) DTracer 20.DRiLLING LOG attach additional sheets K
Geothermal(Heating/Cooling Return) Other( lain under#21 Remarks) FROM TO DESCRIPTION rotor,nn,aaes+,smvrack ;a s;ze
R. ffi O S
4.Date Wen(s)Completed: " a ( wen HM n' j
Sa.Well Location: �5 D S r1aw h SA►h4
�Zre-sko,Y-N pO.'r1e. >,�c
Facility/Owner Name Facility ID#(ifapplicable) % M
It5-i0 / -M!:Y Vrp-w Lh. Lot " OyfarA a-is-6S ft. ft 'd
Physical Address,City,and Zip ft, fL a�
�ranyil�2 10.3®aa. yjS�SS 21-REMARKS
County Parcel Identification No.M
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I 3� sip an El
(if well field,one lat/tong is sufficient)
22.Certification:
3 rn�° I`-1/ �A N 1�° 31 L- %tl w — 3+ 12�- 1
t�•l 1 ,
6-Is(are)the wen(S Permanent or DTemporary Si d Well Contras r Date
By signing this form,l hereby certify flit the wells)was(ivere)Constructed in accordance
7.Is this a repair to an existing well: nYes or 0. with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well CousOuction Standards and that a
ifthis is a repair,fell out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on dre back of thisforna
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-I 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: «� M) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 22@1001 consZetion to the following:'
10.Static water level below top of easing. aQ M) Division of Water Resources,Information Processing Unit,
Ywarer level is above casing use"+" 1617 Mail Seridee Center,Raleigh,NC 27699-1617
11.Borehole diameter. CM.)) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Al r f�O�Uf above,also submit one of this form within 30 days of completion of well
copy,
(Le.au COMFUction to the following
ge,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) Method of test: C500U°�_ 24c.For Water SnDDIv&Iniecdon`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: Amount: I b, completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Ouality-Division of Water Resources Revised 2-22-2016

v
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
L Well Contractor Information:
rG
R�e,n e.l\.f of\ 14.WATERZONFS
well Contractor Name FROM TO DESCREMON
ft. ft.
��as
NC'Arell Contractor Certification Number M
I5.OUTER CASIIYG or maltltssed rvctis OR I.11YY)GRR rf licabie
Stephenson's Well Drilling, Inc. FROM To DIAMETER MAT R
Company Name -1 a �l 1 in_
S 1)�a j V C''
�( I&INNER CASIPIG OR TUBING thermal closed-loon)
2.Well Construction Permit#. 3a��3 ` FROM I To I DIAMETERI TWCKNM I MATERIAL
List all applicable nel1 canstruction parmits A&UiC Cotmt}:State.Variance,etc) % ft- In,
3.Well Use(checkwell use). IL n to
Water Supply Well-. i�.Se[eEsri
bROM TO DIAMETER I SLOTSECE I THICKNESS MATERIAL
Agricultural DMunicipamblic A is ft, io
Geothermal(Heating/Cooling Supply) .01t sidential Water Supply(single) AI rL
RIndustrial/Commercial DResidential Water Supply(shared) 18.GROUT
hTigation FROM TO MATERIAL EMPLACEMENT METHOD&AM0UNr
Non-Water Supply Well: fi: R PrAtUrS r
Monitoring Rocovcry ft. IL C
Injection Well:
ft. tL
Aquifer Recharge DGrotmdwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO PACK MATERIAL
- EMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage ft
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) DTmcer 20.DRQ.i.ING LOG attach additional sheets if
Geothermal(Heatin Cooling Return _- Other( lain under#21 Remarks) FROM To DESCRiPRON color. 501hruck toe,undo size ctr-
ft. R J
4.Date Well(s)Completed: 'oZa."oLl WeU ID#
5a.Well Location: $' ft' $ S T -toll
�O'Ae- LLB- 1 S �d a.
Facility/OwnerNamo Facility M#(ifapplicoblc) ft•
ft. fL �uu
Physical Address,City,and Zip ft' R A n
QT-CQ.1�.1.'V r I I 2 2L REMARKS
County Parcel ideatification No.(PIN) I�i�lGil.3$tOn f^s,•r:.
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(if well field,one latftong is sufficient) 22.Certification:
N ��° 31/ `t�tl W
6.Is(are)the well(s) Permanent _ or DTemporary Si fi well ContractorDate
By signing this form•I hereby certify dim the rneA(s)trans(were)constructed in acrordmice
7.Is this a repair to an existing well: [3Yes or dNo u*h ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Welt Consbucrion Standards and that a
iftb&is a repair,fdl out known weUcowtnrctian information and explain the nature ofthe con,aftUr record has been provided to thetirell oimer.
repair under#21 remarks section anon the back gfthisform.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
^^ (� t� SMMiTTAL INSTRUCTIONS
9.Total well depth below land surface: oL V J (R) Z4a.For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths jfd{�erertt(taample 3Q200'and 2@7003 construction to the following:
10.Static water level below to of
easing:easin g• a (k) Division of Water Resources,Information Processing Unit;
Ifuvrer level is abor a casing.use`+ 1617 Mail Service Center,Raleigh,NC 27699-1617
it.Borehole diameter. (in.) 24b.For Injection Wells: k i addition'to sending the form to the address in 24a
r above,also submit one copy'of this foam within 30 days of completion of well
12.Well construction method: r Mt
(i.e.auger,mtary,cable.direct push,etc.) construction to tide following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resour p es,Underground Injection Control Program,
1636 Mail Servtice Center,Raleigh,NC 27699-1636
d I E
13a.Yield(gpm) 'Method of test; G. 24c.For Water Stmnly&Injection Wells: In addition to sending the form to
1 1 the addtess(es) above, also submit one copy of this fort within 30 days of
13b.Disinfection type: \T H Amount: 1 r completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnviromnental Oualitv-Division of Water Resources Revised 2-22 2016