GW1-2022-05899_Well Construction - GW1_20220627

WELL CONSTRUCTION RECORD(GW-I) For Intemal Use Only:
1.well Contractor Information:
V Ar Qy T S+Puke—11 J©r, 14.WATERZONES
FROM TO DESCREMON
Well Contractor Nam fL M
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LINER If a licableY.
Stephen$on`S Well Drilling Inc. �t0M TO DrAnIEPER rmt3tivEss MATEttIAI
ft, S' rt l SDk a( v Z,
Company Name I m.INNER CASING OR TUBING(geothermal closed-Ioo
2.Well Construction Permit#: 3� b FROM I To DIAMEralt I THICKNESS I MATRIU L
List all applicable well constructfonpermits(t.e.UIC.Count}:State,Variance,etG) #1A I R• in.
3.Well Use(check well use): R. IL In.
11.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTsizE TMCIG%TSS MATERIAL
Agricultural [DMunicipal/Public tt: % in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
Industriai/Commcrcial QResidential Water Supply(shared) I&GROUT "
Irrigation
FROM TOO nn MATERIAL EMPLACEI4UN METHOD&AMOUNT
Non-Water Supply Well: R' a V fL /� 0 l
Monitoring Recovery fL ft -
lWiection Well: f. fL
B
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK�3 livable '
Aquifer Storage and Recovery DSalitnty Barrier FROM TO MATERML EM1iPLACEhUTT 11tETHOD
Aquifer Test OStormwater Drainage D•
Experimental Technology OSubsidence Control IL
Geothermal(Closed Loop) OTracer 20.DRU.I:INGLOG attach additional sheets if access
FROM TO DESCRUMON color.bvrdnm%watroek -etc
a
Geothermal(Heating/Cooling Return) `) Other(explain under#21 Remarks) ft. �. -ro .l-�•
4.Date Well(s)Completed: _o� ��• Well W# R' S n' D� S- 11
Sa.Well Location: mo S
I 1 1A l,�r ft. fL -s _ ".;�, .'t .t^
Facility/Owner Name Facility lD#(ifapplicable) D• fL
� � Cv,16ce,�h �•c�t S{�,Iti. RI ,L. a�s�e % JUN 2, 7
2022
Physical Address,City,and Zip
21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes.1seconds or decimal degrees:
(if welt field,one lat/long is sufficient) 22.Certification:
N �1` ° 3' Wa l as
6_.Is(a_re)the well(s); ermanent or Temporary Signiftdc ofrertifiell WellContractorf Date
By signing this farm.I hereby certify that rite ueQ(s)was(were)constructed in accordance
7.Is this a repair to as existing well: Dyes or-dNo rwith 15ANCAC 02C_0160 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,f711 out known well construction information and explain die nature of the copy ofIhis record has been provided to Ilia well owner.
repair under#21 remarAx section or on the back ofrhisfarm
23.Site diagram or additional well details:
S.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 well
co .0 only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S, 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2 700) construction to the following:
10.Static water level below top of casing: -® 0L) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use-+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter. Es (m) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Nr, above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: �t`I P ffi construction to the following:
(Le.auger,rotary,cable,directpush,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) ly)_ Method of test: T O,U°)e, 24c.For Water SuDDiv&Injection Wells: In addition to sending the form to
the addsess(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: I b . completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016