GW1-2021-02478_Well Construction - GW1_20210930

WEU CONSTRUCTION RECORD(GW-1) For lnoamal Use Only:
L Wen Contractor Information: I
I ��>?A he.� S 0 r la.WATSRZONeS
FROM TO DESCRIPriON
We1lContraetarName dQ ft: d s, rL
NC Well Contractor Certification Nombw IS.OUTBR CASIIYG multl-caged webs QR i
Company Name . FR llesble
Stephenson's Well Drilling, Inc. IMM To Nm4 mR Tm 1HA
ILI sq IL 6l W_ spy. ai P c'
3 3� �, � ><& CASlNGQRTt1BII�fG elased�t
2.Well Construction Permit#: FROM To MANLIER I THtcrawas IegATERrAr.
Liss all gappcab/e rndl eonsductioapermits r e:f11C County:Swa Yartanm etc) R % In.
3.Well Use(check well user M n
water Supply Well: FROM TO DtAt1MM SLOTSEM MATEMAL
Agricultural []MuoiclpaUPublic A tZ D. In.
Geothermal(HeatinWCooling Supply) ORcsidential Water Supply(single) R M f is
1ndustrid/Commerciai 01tesidential Water Supply(shared) 18,GROUT
liri lion FROM TO MATERML S&97AC9KENrMErnon& MO0lgT
Nod-Water Supply Well: ft- ft- Nedonife t S-91b bc4 —
Monitoring !t M C • s _
injection WdL.
RAquifer Recharge Groundwater Remediation
t9 SAND/GRAVELPACti e
Agnifier Storage and Recovery DSalinity Barrier FROM TO I MATERIAL iMPLACE&MM METHOD
AquiferTest DstormwaterDrainage ft.ed mental Technology OSubsidatce Control % ft,
Geothermal(Closed Loop) DTracer 20.DRiLf iNG LOG attach additional sheds R
Geothermal eafmg/Coo• Return) MOilter(mplainundcr#21 Remarks) FROM TO DF$CRH[1 N`mar. wnhedr slat
(� fR I &. Iraf
4.Date wells)Completed: -\' 13 Wen M# n' C
Sa.Well Location: &' S� h G r�1
1 s c e_sho.r^ VISAe- LLQ- S ft. as 51 R c
Facility/OmasNamc FeilityM#(if Wlimble) ft a.
4111 Err.l�j Lpne,_d cI aCAs65 Lot M M
BprTIVED
PhrjcW Address, nY.and 4 ft fL
CTro,ny;lie 1`�3��1g%%�1'�, 2.RMARn
County ParoelidantiflcationNo.(PM O Orm3 loll PFrjCeSz5h1!j HMO
5b.Latitude and longitude in degreWminut ea/seconds or decimal degrees: MAR
(if well field,one Indiong is sufficient) 22.Certification:
Z�( 3 14' V1// N W T.
6.Is(am)the wens erimmnt or Temporary Sf, C Wc11 Conaaeto Dare
By d*fom f h—ty cue dw roe w t)was ftam)cortowed in aoordarue
7.Is thisa repair to nn exIsting wen: 13eyes or oNo 'Wh ISA NOW 02C_0100 or1SA NCAC 02CMW IFeit Canshudion Skondardrand that a
lfdask a repfr,fn7owknown well cmrmatian information dad c plam thenwomofthe copyoflbtsremrd basbeen proW"to theireUotvner.
repair under#21 mmarkrseWan Oran die back oftbirforar
23.Site dlagrsm or additional well detaffs:
8.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. Yon may also attach additional pages ifnecommly.
dn71c: 1. SUBMWAL INSTRUCTIONS
9.Total well depth below land suMce: a Q, 5— (fL) 24a.Far All Wells: Submit this form within 30 days of completion of well
For mnit k we&MtaUdepAr ssf4b=t(=mp1-3Q2W'ar d2*10M construpon to the fallowing:
10.Static water level below top of casing: 3() tft) Division of Water Resources,Information Processing Unit,
if rrarerlevel it above casing.rase'+� 1617 Muff Service Center,Raleigh,NC 27699-1617
Il.Borehole diameter: /� 24b.For Infection Wens: In addition to sending the form to the address in 24a
12.Well construction method: A.r NO-yG r y above,also submit one copy�of this form within 30 days of mmpleflon of well
(Le.auger,rotary,cable ditwt pus%cm) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Infection Control Program,
16M Mali Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:---'�`�Q, 24c.For Water Simply 8t Infection 1n addition to sending the form to
the address(es) above, also 'submit am copy of this form within 30 days of
13b.Disinfection type: HTH Amount- I lb. completion of well construction to the county beahh depattateat of the county
what constructed.
r,.....r:Qr-1 North Curolma Dew ofEnvironmentat OrmW-Division of oicritescurcrs Revised 2 22 2016