GW1-2022-08297_Well Construction - GW1_20220519

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
14.WATERZONES Well Contractor Name FROM TO DE OUTrION
31
c�® S o\Q n
NC 1A'e11 ContractorCertifieationNurber 15.OUTER CASING or nualW'caied welli.OR LAVER ]icable
StephenSOn's Well Drilling, Inc. FROM To DM WIER THICiQVESS MATERIAL
Company Name Q fL 3 R I in. S I N
16.FeMR CASING OR TUBIBrG& Bernal closeddoo
2.Well Construction Permit#: 3 C d-\a FROM TO DLtMi'M ITS[CKNFSS MATERiAL
List all applicable will construction permits(i e.UIC.Cow*,.States Parlance etc) ft- f in.
3.Well Use(checkwell use): % % in.
Water Supply Well: 17.SCREEN
FROM TO DiAM."M I SLOTSiZE I TMCKNESS MATERM
Agricultural OMunicipaMblic NIA [L it. In
Geothermal(Hcating/Cooling Supply) .01tcsidential Water Supply(single) Io, In.
IndusttiaUCommerciat Olkesidential Water Supply(shared) 1&GROUT
hTization FROM TO I MATERL►L EMPLACEM NT MEMOD&AMOUNT
Non-Water Supply Well: tL a Q,` ( SQ b r
OMonitoring ORecovery ft. & ��
Injection Welh
IL tt
EGeothermal
ifer Recharge DGmmmdwater Remediation
Aquifer Storage and Recovery O�-•�,Salmi Barrier R SAND/GRAVEL PACK a le
g ry lam' ty FROM TO MA.TERiAL EhtPLACEh1EpThiE1ROD
ifer Test QlStormwater Drainage M h
erimental Technology OSubsidence Control tt %thermal(Closed Loop) DTM= 20.DRII.LING LOG attach addtoonal sheetsifnec(Heating/Cooling Retum) nOther( lain under#21 Remarks) FROM I TO DEiCttIPTiON mler =ouraekSim ew
ft %
fQ.
ft. ft.
4.Date Well(s)Completed: Well ID# i 1d �, o,
So.Well Location: D' a f .1 .1011
GO'ni V'11, 6rl as 9 2),f R
Facility/o%6crName Facility MN(ifapplicable) f IL
313 5 'arch L-rt,e, (14orl 21S S-S� % fL
Physical Addmxs,ON and Zip R'
Qi co,fny; ?1'REPAARKS
County Parent Idcnffcation No.(PIN) r p
5b.Latitude and longitude in degreesimi outesiseconds or decimal degrees: '` i`'°'
(if wall field,one laMong is sufficient) 2L Certification:
N —lP W &�Q�
6.Is(are)the well(s)OPermanent or OTemporary Sigmifide ofCafificil Well Coatractbr Dale
By signing this form.l hereby eensf that the vell(s)nus(were)consttrtcted in accordmice
7.Is this a repair to an existing well: Oyes or,ONo ulth ISA NCAC 02C.0100 ar ISA NCAC 02C.0200 Well Construction Standards and that a
ifdtis is a repair fdl out known well construction information and explain the nature oftlie ropy affhis record has been provided to theirell otmer.
repair under#21 remarks section or on de backofthtsform
23.Site diagram or additional well details:
&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
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells construction details_ You may,also attach additional pages ifnecessary.
drilled: .1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (�) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For-1hple wdk list all depths ifdtff—f(—ple-3@200'ond 1@1001 construction to the following:
i
10.Static water level below top of casing. #L) Division of Water Resources,Information Processing Unit,
If tvorerlevel is above easing.use"+" 16I7 Mail Servllee Center,Raleigh,NC 27699-1617
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11.Borehole diameter. (m.) 24b.Bur Inieetion Wells: In addition to sending the form to the address in 24a
2.Well construction method: i 6�0�f�l above,also submit one copy 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 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) c::):,- Method of test: 24c.For Water Supply&I election Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: VAT VA Amount: completion 1 b• completion of wen construction to the county health department of the county
where constnrcted.
P.m ref-1 North Carolina DeoMment ofEavimnrffinml Ouality-Division of WaterResources Revised 1-22 2016