GW1-2022-05815_Well Construction - GW1_20220609

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WELL CONSTRUCTION RECORD(GW-1) For I tmmoi Use Only.
1.Weil contractor Information: (�
14.WATERZON83 !
Well Contractor Name via= To I DESCRI MON
2
NC Well ConnactorCertificationNmnber 11 OuTim, ASING formwd Wells ORLINER e
Stephenson IS Well Drilling, Inc. FRo To D�>rmI MUCOWN MATS'
R a• I Sp(�Company Name al i I?-q r,
�0 16.INNER CASING ORTi1BIIYG. ehued-t
2.Well Construction Permit#: FROM TO 1.DfAMEl6R Tm MA1tiR1At.
List all applicable utrll eonmcdon permits 0.0.tJ/C Cotu*a Stotu Yadance:etA) it
3.Well Use(check well use): n' in.Water Supply Wd1: ?.NWK To I DLAme R SGO?s1T8 I TMCHNM I MATEauL
Agricultural MumicipaVPublic R n, hL
.. Geothermal(Heating/Cooling Supply) 01tesidential Water Supply(single) R 2 „ ",
lndustdal/Commcrcial DResidential Water supply(shared) 11L GROUT
Inigation FROM TO MATERIAL ENEM ACEMErir11 MOD$AMODNr
Non-Water Supply well: Q Q11
Monitorin Rtxovcry
Injection e • R
Aquifer Recharge (DGmundwater Remediation
Aquifer Storage and Recovery Dsalinity Barrie FROM TO 19 SAt+1DlGtt TO PwCK a MAT EWAL l AL
EMPL►CE1ffiNTMETHOD
Aquifer Test OStormwater Drainage plIA R• rG
Experimental Technology OSnbsidence Control ft. ft.
Geothermal(Closed Loop) OTrd= 20.DPHJMG I.M attach additional tduels R
_ Geothermal eatin oolin Rd=) rJOther(atplainunder#21 Remarks) FROM TO DFscamioN Wakeae type.grain 212L ate.
n. i R i o -r'o'
4.Date Well(s)Completed: %-aaWell ID#
Se.Well Location: D' sook.1 X
61
uo UMMJAv l Ike r silv�rLeu,� )-16t- O\`Z lor ff a65R
Facility/OamerName Facility W#(ifWUwbk)
3`i-t0 Socinc`Fie,ld �co:ml �oV.nClville �-1 S"�S ft. " I •�
Physical dAd&ess.City,amend Zip D' ft '"C
�OvJre, N aIA00O\a,1 a.tg 21.REMAJUN RKS
County Parcel Identification No.R" 0
Sb.Latitude and longitude In degreesfAdmites/seconds or decimal degrees: W.M,oinzn PrnczGc�naU nh
(ifwell field,one Wong is sufficient) 22.Certification: � Dk&JQ FBOG
N 33/ �i1 W
6.Is(am)the weII(s)OPermanent or DTemporary sionfurd#Ncertim well cmatacar — Date
BY sUning dds fortm 1 hereby car*d&the MUM tans(uxne)cmutructt'd in accordance
7.Is this a repair to an existing well: DYes or oNo udth!JA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standordr and that a
Ifthir is a repair,fdl out known uvfl a tr�ction Wwwarion and explain die namm oftia cM,aphis record has been provided to die wdl owner.
repair under#21 remarks section or on due back of thtsfornc
23.Site diagram or additional well details:
tl.For Geoprobe/DPT or Closed-Loop Geothermal Welts Laving 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 tittadt additional pages if ntxes�ty
chilled: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) 24a. For An Wells: Submit this form within 30 days of completion of well
For-1hple wells Un off depds jdjl—i(example-3@200'and 2@1001 construction to the following
10.Static wear level below top of casing: 3® (ft) Division of Water Resources,Information Processing Unit,
Ifrvaterlevel is above eosbub,use"+` 1617 Mail Service Center,Ralelgh,NC 21699-1617
11.Borehole diameter:_� (in.) y 24b.For Infection Weir'In addition to sending the form to the address in 24a
12.Well construction method: �1 C 1 , .1 a f ab0A"emit one copy of this fbrm within 30 days of completion of well
(Le,auger,rotary,cable•ditect pleb,etc.) construction to the following:
DWlslon of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1L Method of test~ 0.%Jk 24c.For Water Supobt 8E Infection Wells: In addition to sending the form to
the addiess(es) above also submit one copy of this form within 30 days of
13b.Disinfection _type: Amount: h completion of well construction to the county health department of the county
when constuctod.
i
Nnrth Carnlma Dawrtment of Environtombd Oaatity-Division of Water Resource's Revised 2-22 2016