GW1-2021-01858_Well Construction - GW1_20210503

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only. ,
1.Weil Contractor Information:
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�e.�TC2V S�QOkf.Ns OPT 14.WATERZONES
Well Contractor Nalne IMOM TO DESCRIPTION
alas a �6s fL %S ft,
ft. % i
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if licable
Stephenson's Well Drilling, Inc. FROM To DIA1►EEM, T>lzctavEss MATTERIAL.
Company Name fL v' in. S po, :�j 1'V
3��A ` 16.INNER CASING OR T[JBING( doseddoo
2.Well Construction Permit#: "\ FROM To I DULMLTM I TMCKNM MATERIAL
List all applicable well constructionpermits re.UIC,County.State Variance,etc.) ft. in
3.Well Use(check well use): ft. & 'n'
Water Supply Well: 17.SCREEN
FROM TO 7—
I& R SL.OTSUE TMCi NMSS MATERIAL
Agricultural OMmricipaMblic tz ft, n.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) M %Industrial/Commerciat OResidential Water Supply(shared) GROUT
hTi ti0D FROM TO MATERIAL EMPLAC[ME2rr METHOD&ADIOUNT
Non-Water Supply Well: R aQ tz Ur SQ b S
" Monitoring DRecovcry ft. g 11
Injection Well: Chl .f
Aquifer Recharge DGtoundwater Remediation ft. ft.
19:SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METROD
Aquifer Test OStormwater Drainage AdA ft. ft.
Experimental Technology OSubsidence Control iZ ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther( lain under#21 Remarks) FROM I TO DESCRIMON color. •bardnem sevcoclr am etc.
ft. ft O J0
4.Date Weil(s)Completed:4`a� —�( Well 17D# ft. cad ft.
Ss.Well Location: 30 ft' -` ft' ►1 S q S
SSre.sho,m OA
ft. 3$S it
Facility/OwnerNamc Facility lD#(ifappticablc) ft. [t
4 S6°� �s�l�� y�e,w Lh. �-o�l l Oxfor-�► a,56S ft. �' "�
Physical Address,City,and t�. �i d ft• ft•
nV1'ff, �'\3000 1����o D 21-REMARKS- MA, 11
County Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: It Tarl.'3'. PfQG@s5
(if well field,one lat/long is sufficient) 22.Certification: V
6.Is(are)the well(s) or Temporary Si re �d Well Contracto Date
vd By signing this form,l hereby certify that the nell(s)war(uere)constructed in accordance
7.Is this a repair to an existing well: DYes or.ANo ivith ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
if this Is a repair,fill out hnown well construction information and explain the nature of the capJ'ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Ceoprobe/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.
drilled: '.
3 i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (�) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/at all depths ifdifferent(eramph-3@200'and 2@1009 construction to the following
10.Static water level below top of casing. 3 (fL) Division of Water Resources,Information Processing Unit,
If maw level is above casing,use"+~ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy;of this form within 30 days of completion of well
12.Well construction method: 1 f P�0 AC�/ 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 Mari Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) et Method of test: v Q V1Q E 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also sutitnit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. !
Form GW-1 North Carolina Department of Environmental Oualitv-Division of Water Resources 1 Revised 2 22-2016