GW1-2021-02105_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. . .,.
1.Well rrCoontractor Informationn: L
�-P—%r ey S-+'e.D La Q.n f-o n 14.wAIMMON&S
Well Contractor Name /�, FROhT TO DESCRIPTIONI
NC Well Contractor Certification Number 400 fr. 4 o(3 IL
M OUTlM T91G or malt(-cased wens OR LAVER rf lit�W!
Stephenson's Well Drilling, Inc. FROM To DIMMER TffictavEss f MATERIAL
Company Name ft MATERIAL
i is S)P (>V C
� 16.MMCASING OR TUBING -t al closed
2.Well Construction Permit& FROM TO MAMICTM TFUCKNEAS MAT6Rtat
List aft applicable uefl wnstruction permits ri e UIC Ccuat}t Starr;Varianca era) ft. In,
3.Well Use(ebeckwell use): ft. n In.
Water Supply Well: 17.SCREEN
FROM TO DL METER slorslM TMCta''Ess MATEamL
Agricultural �MtmicipaUPublic n, n, 1-
Geothermal(Heating/Cooling Supply) 01tesidential Water Supply(single) hit R ft.
Industrial/Commeteiat DResidential Water Supply(shared) 1&GROUT
,_11nigation FROM To MATERIAL ZKM ACF247rir METHOD&Amon"
Non-Wager Supply Well: 0R ft-. zo-AiQlAe
S-016- boarl
Monitoring 01tecovery B. rZ C • J
Injection Weil•
Aquifer Recharge Groundwater Remediation ft.
Aquifer Storage and Recovery Qlsalinity Barrier FROM GRTO PACK MATMAL EMK AC6t4M'r WFM0D
Aquifer Test DStormwater Drainage R. R
DExperimental Technology DSubsidence Control I Itt R.
Geothermal(Closed Loop) DTtacer 20.DRII.I.ING LOG attach additional sheets R
RGeothermal (Heating/Cooling Return Other(explain under#21 Remaft) I FROM I TO mrscxtteTto>a(color,bodnem sonha&tive,grata seer.#
ft. I scar
4.Date well(s)Completed: of Well ID# U. Le��.S R' Tir_jvr% f
5a.Well Location: as, ft- J S f
-[n's s k It 'nc ,rQr 4Ktx ),at 32L 4QL 5ft-
Facility/Owner Name Facility IDA(ifapplicabk)
tt. M
aEyl Cl\rile, br. , ft.
Physical Address,City,and Zip II• R
Cr r o\n yl l/t- a1.RF.h1ARics
County Parcel identification No.M
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - pCOCeSSin(g Unit
(ifwell field,one lat/long is sufficient) 2L Certification: D,R SOCT'On
& � i�11 N_ -J4 n" 31 I a I w " a 43^ (� _I _r• \
6.Is(are)the well Permanent or [Temporary s); Sa,r3b3 well Contr Date
"�
9 By signing this form.I hereby certify dmr fire lrell(s)tau(mete)constructed in accordance
7.Is this a repair to an existing well: 0Yes .4;6NO with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Canthuction Standards and that a
(f►his it a repafr,fdl out known well construction information and esplain the nature ofdre cM,ofthis record hat been provided to the well owner.
repair under#21 remarks section or on die back ofd&form
23.Site diagram or additional well detst7s•.
S.For Geoprobe/DPY 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.
wed: 1., 4^� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 �C M) 24a. For All wells: Submit I this form within 3t)days of completion of well
Formultiple wells list all depMr jf Brent(rsample-3Q200'ond 2�)00�
(� construction to the following:
10.Static water level below top of casing- 3\Y (M) Division of water Resources,Information Processing Unit,
Iflvater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 276W1617
11.Borehole diameter- (in.) 24b.ForlaieWon webs: In addition to sending the form to the address in 24a
12.Well construction method: ) (' �`A A r l� above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct puslr,etc.) construction t0 the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ` Method of test: y i\%C e. 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also =limit one copy of this form within 30 days of
13b.Disinfection type: HT H Amount:_-A 16% completion of well construction to the county health department of the county
where constructed.
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V..—t:W'-1 North Carolina Deoanmeat of Environmental Oualitv-Division of Water Resources Revised 2-22 2016