GW1-2022-08281_Well Construction - GW1_20220519

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WELL CONSTRUCTION RECORD(GW 4) For Internal Use Only.
1.Well Contractor Information:
e`C`r r&u 1 k S+Q-D�\e-N-r0-\ 14.WATERZONU
WellContractorN FROM TO I DESCRn'170N
ft' 3a.5
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NC Well Contractor Certification Number 15.0UM CASING for moWcaseed wt]is OR LINER rf Iltx>ble
Stephenson's Well Drilling, Inc. FROM To mAn THIC1Q11ESS MAT£RtAL
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Company Name s _
16.RVNERCASWO.ORTUBING doseddoo
2.Well Construction Permit* aPA a��- FROM TO DLUALM R TMCKNESS MATERIAL
List all applicable oall wnstrucdon permils ri e.UIC Comu}t Mate.Variance~eta) A ft ur.
3.Well Use(check well use): % rL
Water Supply Well: 17.SCREEN
PROb1 TO I DUMI:rER sLOTSIai TBICKNTsS I MATERIAL
Agricultural 0Municipal/PubBc % n, is
Geothermal(Reating/Cooling Supply) .01tesidential Water Supply(single) 2 ;�
Industrial/Commcrciat DRosidenfial Water Supply(shared) 18.GROUT
I—blrri lion FROM TO MATERIAL EMPLACEMENrNErnoD&Aalourir
Lon-water supply well: V & 8L0 R i- + n�-2 $- ,p
Monitoring Rceovcry 11L % �h� f
Injection Well:
Aquifer Recharge Damundwater Remediation
19:SANDlGRAVEL PACK a Ilcnble
Aquifer Storage and Recovery OfSalinity Barrier FROM I To MATERIAL. I FMPLACEhM"rN M0D
i Aquifer Test OStormwater Drainage R•
Experimental Technology OSubsidence Control % ft.
RGeothermal(Closed Loop) OTmcer 20.DRII.LING LOG attach additional sheets if
Geothermal(Heatin Cooling Return) 00thcr(expWnunder#21 Remaft) FROM TO DESCRiPnON eator,hardneu aentmek sin--ere
O o 6
4.Date Wells)Completed: a1 Well ID# R' r)Q R' 0./� 1 e..0\ dow
Sa.Well Location:
C, zjae,Vc., �,�r �rye r Lod" S"0 3'*S" fL n c
Facility/OwnerName Facility1D#(ifopplicable) %
r\&L-'d m CT c oil e, L\. g—Ak&rw a, N�e„ an S 3"l tr m
Physical Address,City,and Zap ft. ft'
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V���C e O���(3 ao 2L REMARKS
County Parcel Identification No.(PBO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
'Su IUCI L!kO N � D� d�J W o,., t�;=;;,'•: ;i' l „,. : j ;` ai��,j
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6.Is(are)the weff(s)OPermam d or rJTemporary Si well Contras r Date
By signing this farm I hereby cervfy that the iseR(s):vas(were)cam*acted in accordmrce
7.Is this a repair to an existing well: r1Yes or ONo uft 11A NCAC 02C.0100 or 11A NCAC 02C.0100 Well Cansn action Standards and that a
lfdrrs is a repakfdl out known rveBronstruetion Information and erplarn the nature oftlre copy ofthis record has been provided to die well owner.
repair under#21 remarks section or on dte back of thisform
23.Site diagram or additional well details:
ti.For GeoprobelDPT 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. You may also attach additional pages ifnecessary.
drMed: 1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 A S (A) 24a. For All Wells: Submit this form within 30 days of completion of well
For mudiple wells list all depths ifdV-1(—pl-3(a)100'and 1Q1009 construction to the following:
10.Static water level below top of casing: a #L) Division of Water 12esources,Information Processing Unit,
If inter level is above casing.use-+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Welir. In addition to sending the form to the address in 24a
AA 12.Well construction method: f �6 Ar above,also submit one copy of this form within 30 days of completion of well
/C 1 ��
(i.e.auge,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: ('V 0,, 4?- 24c.For Water Sun DIv&Injection Wells: to addition to sending the form to
the addm(es) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Amount: ,V . completion of well constructioa to the county health department of the county
where constructed.
F...,r:W-t Nnrth Camlina Deradment ofEnvimnumntal Ouality-Division of WaterRescurces Revised 2-22 2016