GW1-2021-07406_Well Construction - GW1_20210921

Q
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Wen Contractor Information:
e f y\ 14.WATERZONES
Well Contractor Naint FROM To DESCRIP R ION
\`sR � 5 � �s �P
NC Well Contractor Certification Number 550 I%
0UM CTANGor mMO U khle
o �
Stephenson's Well Drilling, Inc. °\\ RM � MATE RIAL
Q CosupnnyName IL 53 ft. 6/ in. SIA at C,
\�
i6.IIViYBRCAS'IPiG OR TUBIIYG at elase"
2.Well Construction Permit#: D FRO TO DIAMETER TIUCi MESS MATERIAL
Litt all applicable urll consbvctionpernuts i.e.UiC Gazing:Stag Variance-etc.) % In.
3.Well Use(check well use): n' fL tn.
water supply Well: 11
Maid TO DIAMETER L Sf.OTS= THUX(NIM-1 MATERIAL
Agricultural DMunicipaUPublic ft. IL fa
Geothermal(Hcating/Cooling Supply) ffRcsidential Water Supply(single) At 11A
FL In
Industrial/Commcrciai DResidential water supply(shared) i&GROUT
rInjection
FROM To MATERIAL EMPLACEMFNi'METHOD&AMOUNT
upply Well: R fL ^ }Q, SQ ,r
Recovery R ft C
ll: ft %
charge �iGrotmdwaterRemediation
19.SANWORAVEL PACK f eablerage and Recovery Salinity Barrier FROM TO MATERIAL I ENIPLACErtnorr ME RoD
AquiferTest DStormwater Drainage u A ff-
Experimental Technology OSubsidence Control R fL
Geothermal(Closed Loop) DTnicer 20 DRILLING LOG attach additional sheets if
_ Geothermal(Heating/CoolingReturn Other( lain under#21 Remalits) FROM To DFSCRiPftO1Q eofor,traraoess soutroett sia,
G� ® ft. ft. 00-ro
4.Date Wells)Completed: -\- �� Well ID# n' a n' C INV
5a.Well Location:
�sr�, s�o•r. �o►n1e. LLC
Facility/OwncrName Facility IN(ifappUcable) D• fL
L t 5�,S ksk11:•1 \4;9,w L I\ 4X�or Loft 5 ft. R.
Physical Address,City.and ilp ft. ft.
2L REMARKS
County Parcel ldeMifirationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufflcicat) 22.Certification:
N S3tt w
C\-1-ao
6.Is(Sre)the well(sPernlsuent of D'I'emporary
Si )outracibr, Date
By s4p-g thu form.I hereby certify that the KWI(t)runs(were)constructed in accordmrce
7.Is this a repair to an esisting weD: [3Yes or izNo ulth 1SA NGIC 01C_0100 or ISA NCAC 02C.0200 Well Coun7ru an Standards and that a
lfdtis is a repair,Jill out known svell canitruction b fmmarian and 4opZdn the nature ofthe con,afthisremrd has been provided to the imll otmer.
repair under#21 remarlasection or on die back ofthisform
23.Site diagram or addItionaiwell detttits-.
8.For Geoprobe/DPT or Closed-Loop Geothermal WeHs having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of welts construction details. You may also attach additional pages if necessary.
drilled.— SIMMMAL INSTRUCTIONS
9.Total well depth below land surface: !, (t) 24a,For All Weis: Submit this farm within 30 days of completion of well
Forrnu/Crple wells&t all dgff&,f1 4 Janet(—p/e-3Qa 200'and 2@1003 construction to the following:
10.Static water level below top of casing. -SO (ft) Division of Water Resources,Information Processing Unit,
ljumrer level is abase cmvr&use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (bu)
0p 24b.For Infection Wells. to addition to sending the form to the address in 24a
12.Well construction method: /-//���1 Ic f\0 V A r q above;also submit one copyr of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) : construction to the following i
FOR WATER SUPPLY WELLS C ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27695406
13a.Yield(gpm) Method of test: QV o"k A ' C, 24c.For Water Supply&Infection Webs: to addition to sending the form to
the addtem(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: bT Amount: 1 h s completion of well construction to the county health department of the county
where constructed.
R.—r.Vu-t North Carolina Deoadment ofEuvimnmenral Ouality-Division of WawReso— Revised 2-22-2016