GW1-2021-02724_Well Construction - GW1_20210512

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WELL CONSTRUCTION RECORD fQW-1) For Internal Use Only.
1.Well Contractor Information: 7F
l L
�e�C r-2.� T . S"f e,of\2.n.r 0►� 14.WATERZONES
Well Contractor N e FROM TO DESCRIPTION
& It i
NC Well Contractor Certification Numbs
15 OUTER CASIIYG fir molti�casea wells OR LINER rr Ifcabie
Stephenson's Well Drilling, Inc. FROM To DIMIElER ,� MATERIAL
ft- ' In. sDA a V C,
Company Name
16.INNER CASING OR Tf1BING(geothermal dosed-too
2.Well Construction Permit#. FROM TO DIAMtTTER TIDCTON&4S I MATERter
List all applicable uell aonstruedanpetmils fr.e.WC.Couapt State.Variance etc.) % % In.
3.Well Use(check well use): % % In.
Water Supply Well: 17.SCREEN
FROM TO MWETER SLOT SITE THICHNESS MATERIAL
Agricultural DMunicipamblic Al JA ti % In.
Geothermal(Heating/Cooling Supply) 01tesidential Water Supply(single) V tz IL In.
industrial/Commercial DResidentiai Water Supply(shared) 1s.GROUT
i ri ation FROM TO MAMMUL EKK ACEMENTME MOD&AMOUNT
Non-Water Supply Well: & a M it Pam.- SQlb
Monitoring ORccovcry ft. & C
injection Well: J
fl: ft.
Aquifer Recharge DGroundwater Remediation
19:SAND/GRAVEL PACK icabk
Aquifer Storage and Recovery Dsalinity Banier FROM TO I MATERTAL I EMPiACEhTBNT METHOD
Aquifer Test OStormwater Drainage $
NExperimental Technology OSubsidence Control tt ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) rjOlher(cxplain under#21 Remarks) FROM TO DESt7tIPiioN corer. wufraek sly etc.
d % & 0 J I
4.Date Well(s)Completed: " "a� Well ID# ft. a.� It, C.I o
Sa.Well Location: o�S D- 1 J ft- SroviN xl�n r0
CSc-e,s�arr• ?Cl'Ae, LL. S ft `t S tt e
Facility/OamerName Facility iD#(ifapplicable) %
Physical Address.C' ,and Zip c� ft. ft.
V'rDAVtIIP. J 0� 2LREMAIM
County Parcel ldentification No.(PIN) ion PCOcessing t1t111
DWR Secron
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) �r 22.Certification:
s /3 6i I'A �3(/ N Z D ° 31 � s'A" W �r s r a`
6 Is(am)the well(s� er Pmanent or Temporary Si cll Contractor Date
By signing this form 1 hereby certify that the well(s)war(were)constructed In acmidmuce
7.Is this a repair to an existing well: Dyes or-ONO u th 11ANCAC 02C.0100 or ISA NCAC 02C.0200 Nell Construction Standardr and that a
ff dds is a repair,fdl out Amonar tuell construction information and explain the nature ofthe copy afthis record has been provided to de well owner_
repair under#21 remarks section or on due back of thtsforac
23.Site diagram or additional well detar'La-.
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or Weil
construction,only 1 GW-t is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
wed' 3- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface. 3 LA (L) 24a, For An Wells: Submit this form within 30 days of completion of well
For mullip/e wells list all depths ifdrfjerent(emmple-3@200'and 2@1001 Construction to the following:
10.Static water level below top of easing: 5 (ft} Division of Water Resources,information Processing Unit,
Ifwater level is above easing,use-+- 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: d (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: K f MtCk r V above,also submit one copyy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 14Method of test: A 9.., 24c.For Water SUDply&Intecion Wells: in addition to sending the form to
T the addless(es) above, also 'submit one copy of this form within 30 dabs of
13b.Disinfection type: 1 Amonat: J- 16 , completion of well construction m the cotruty health department of the county
where constructed
V..—r.W-t Nnnh Camlina newrtment of Environmental Ouality-Division of Water Resources Revised 2-22-2016