GW1-2022-08783_Well Construction - GW1_20220909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�e.`F`C 2�1 ) • ��Q A�Q•f 1 Q (� i�xoni TO DESCRIMO t
ftil Contractor Name v R. Q R S (zy e f n
NC Well Contractor Certification Nurr#r M OUTER CASING for moiti+ceI ed wells NE OR LIR if a 6cabie)
StephenSOn'S Well Drilling, Inc. FROM To DIAMEM THICMESS MATERIAL
�- in. sD at pvc,
Company Name 16.INNER.CASING Olt TUBIIYG( U.M.ldoseddo
2.Well Construction Permit#. r-r I!i I o h FROM4t —r-0
It. I)MMETM THICKKM MATFDiAL
List all applicable nrll oonslrucd0trpermft Xe-U Caano-.State Yuri-=eu) ILi'
3.Well Use(check well use):
17.SCREEN
Water Supply Well: RWIVI I TO IDiAMEr£R SLOTSITE TIHCIO�FSS MAT[RIAt
Agricu{tural [)Nhmitdpal/Public iL ft. in
Geothermal(Heating/Cooling Supply) 0Rcsidential Water Supply(single) % in
industrial/Commt tciat Residential Water Supply(sham) 1&GROUT
Irti lion FROM TO MATERIAL EM Q�PLACFA aMETHOD&A1110t11VT
Non-Water Supply Well: Q R" �0 g �¢
Monitoring DRecovcry & tit C hl 1
Injection Well: R.
Aquifer Recharge OGmzmdwaterRemediation
19 SANDiGRAVEL PACK rf a licable
Aquifer Storage and Recovery Dsaflnity Barrier FROM I TO I MATERIAL EMPLACOVIEh'T fV%TROD
Aquifer Test OStormwater Drainage $• R'
kExperimental Technology OSnbsidence Control ft it.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other( lain under IF21 Rt maths) FROM To nFstxuPrtoty mica Lsraness.sonhoeli sin cue
ft. 1 0 40,. 1 .
4.Date Well(s)Completed: "o�°� ova.Well ID# D' D' P—v` C 00
Sa.Well Location:
�3 a K
Facility/OamerName IL
I=ilityM'.(if appli cab lc) ft. R'
POn& lot Y0VAglV1,1Q, 9L1 S°\6 ft. ft
Physical Address.City,and Trp % & 9'
�r o A I; . I rl S-LA4 0'%5 21.REMARKS
County Parcelldentifi�ationNo.(PII� P`ca✓:'aing UnA
D•.u/k�.
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
`f S"// N _ 1" aA/ a S/t W
6.Is are the wells _ ermanent or OTemporary S" Certified%Vdl Contra*or Date _
By signing this form.l hereby certify drat the aid/(s)was f%w, 4 constructed in accordance
7.1s this a repair to an existing well: Dyes or'ONo utith 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wefl Construction Standards and that a
Ythis is a repair,fdl oat known well construction information and explain the nature of the copy ofthis record has been provided to the ivell owner.
repair under R21 renwrla sec'loa or on the bad-ofthisform.
23.Site diagram or additional well details:
8.For GeoprobefM 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 if necessary.
1 SUBMITTAL INSTRUG'I'IONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrff—i(ammple-3Q200 g
rand 2@1001 construction to the followin
Io.Static water level below top of rasing. is-
UP Division of Wafer Resource,Information Processing Unit,
Ijtvater level it above casing.use'+C 16I7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamet ev. 6 rm•) 24b.For Iniection Wells 1.addition to sending the form to the address in 24a
.} above,also submit one-copy of this form within 30 days of completion of well
12.Well construction method.- t �0 14 t �� constriction to the following:
(i.e.auger,rotary,cable;direct Ptah,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) Method of test; AVt c _ 24c.For Water Supply&Injection Wells: In addition to_sending the form to
the address(es) above, also submit one copy of this fowl within 30 days of
13b Disinfection type; 11 1 N Amount: 1 I b. completion of well constriction to the county health deparhnent of the county