GW1-2021-02325_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW41) For Internal Use Only.
1.Well Contractor Information: ll
14.WATERZONES
Well Contractor Name FROM TO DESCREMON
am & %a:1 & �� CY
NC Well Contractor Certification Number
15 OUTER CASING fror multi=cased wells OR LINER Cif llcahie
Stephenson's Well Drilling, Inc. FROM TO DIADIEM TIOCOMS MATFerer
CompanyNnme ft `J ft. �I % in. S��a �,
��� I&INNER CASING OR TUBDYG t at dined-I
2.Well Construction Permit#: TO I Dt"MSTEtt I TtTtetavPss I MATE1tTAL
List all applicable will construction permits rEe.UiC Couagt Site.Variance,etc) jv1A ft ft in.
3.Well Use(check well use): % M in,
Water Supply Wei{: ]FROM
SCREEN
FROM TO DIAMCTER SLOTSUZ T§nCXNTs5 MATERIAL
Agricultural DMunicipal/PubGc WA fL ft to
Geothermal(Heating/Cooling Supply) *Q(Residential,Water Supply(single) n. M
Industriai/Commemial Residential Water Supply(shared) 11L GROUT
lrfl tion FROM TO MATERIAL Von ACEMErfF bM1rHOD&AlV10QNT
Non-Water Supply Well: nib ba
Monitoring Rocovtxy ft &
injection Well:
ft. ft.
quifer Recharge Damundwater Remediation
Aquifer Stotage and Recovery Salinity Barrier m SAND/GRTO PACK a le
FRO TO MATERTAL EMPLACFhi®vTi11E'[ITOD
Aquifer Test [3Stormwater Drainage ft.
Experimental Technology OSubsidence Control it ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheet:if
RGeothermal
(Heating/Cooling Return - Other lain under#21 Remanirs FROM m DFStxtTP[TON eolor. aoNrodr ssmete
O ft. ft. T jo tl
4.Date Wetl(s)Completed: E- �-�� Weu HW ft• sr n•
So.Well Location: a r ft' 'T % S n�
�SOwI l�'i®r•r gt�;,l�e,r W�nc�f Qr L�,K of TA �{ ft. a$S,
Facility/OamcrName �- Facility W#(ifappliwble) ft. M v; ^
`tS63 �oyf��I�1 Lhi Frorl nir•`�on a1Sas f. ft.
Physical Address.CityTand Zip ft. ft• 02.1
21.REMARKS
County Pmc&Ideati mation No.(PIN)
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees: Dvti v
(if well Gold,one ht/long is sufficient) 22.Certification:
3�oQ N. �I) 1��� W
6.1s(are)the well(s)OPermanent or OTemporary S at Weu Contracoof Date
By signing dir form f hereby terrify that dre nell(s)im(mere)cowwwed in accordance
7.Is this a repair to an existing well: Dyes or.6NO utith 15A NCAC 01C.0100 or ISA NCAC 02C.0200 We11 Construction Standards and that a
Y&&is a repair,fd►am knoum ivellconstruction information and=plain the nature oft1w cm,ofthis record has been provided to theiw*ovow
repair under#21 remarks section or on de backofildsform
23.Site diagram or additions[well details.
g.For Geeprobe/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
constructiog only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 76 q� r SUBDIMAL INSTRUCTIONS
9.Total well depth below land surface: (M)
For multiplewellsrwalldepda fdijjerent(emmphr-3Qa200'and2Q100� For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 3Q (ft) Division of Water Resources,Information Processing Unit,
1f nester kwJ is abowe casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: � (M.) 24b.For Iniection Wells: in addition to sending the form to the address in 24a
QQ above;also submit one copy!of this form within 30 days of completion of well
12.Well construction method: Air `\0 a f y construction to the followin
(i.e.auger.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~ C-1 AV.5421 _ 24c.For Water Soun y d:Infection Wells: In addition to sending the form to
the addtess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: _T -_ Amount: r completion of well coustructim to the county health department of the county
where constructed.
r--r.w-t North Carolina Deomtment of Environmental Orolity-Division of Water Resources Revisal 2 22-2016