GW1-2022-09116_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use only-
1.Well Contractor Information:
FROM Well Contractor Name TO DESCREMONt r 36a ft -5On IL f3% Ql !N�1
Afc n
NC,%klcll Contractor Certification Numbcr is.OUTER gMIN, ar�Ircesed wells OR i.IAiER tC le)
Stephenson's Well Drilling, Inc. FROM TO Dl�ntr;1�R '� MATERIAL
Company Name ft. •V IL 1 in. S �. \f Q,
3 ty 16.INNER CASING OR TIJBIlKG( mat etosed-t
31
2.Well Construction Permit* "\ MOM To I DL+KUM TmCfQ M MATERIAL
List all applicable mall eonstntction permits(1-M IIIC Comt4:State,Variance,etc) ft.
3.Well Use(checkwell use): ft' tL in
Water Su 17-SCREEN
Supply Well: FROM TO DIAMETER EsLarsam I Tmm7ESS I MATERIAL
Agricultural ONhmicipaMblic ft. ft.
Geothermal(ffcati*Cooling Supply) Residential Water Supply(single) IL a in,
IndustriallCommcreiai ORwidential Water Supply(shared) i&GROUT
nhTigation FROM TO MATERIAL EMPLACEaiFnW METHOD&ADIODT iT
Non-Water Supply Well: ft' aQ ft' n v, S0� r
i- Monitoring DRccovcry it. % C J
Injection Weil• ft, ft.
Aquifer Recharge nGroimdwaterRemediation
19:SAND/GRAVEL PACK d a lttmbte
Aquifer Storage and Recovery OSalinity Barrier mom TO I MATFRUL I EMPLACEMEhTKW MOD
Aquifer Test DStormwater Drainage M A ft
Experimental Technology OSubsidence Control R ft.
Geothermal(Closed Loop) Tracer 20.DRILi.IiVG LOG attach additional sheets;if
-. Geothermal(Heating/Cooling Retain) F101her(explain under#21 Remarks) FROM To DESCR PnGN-I-t-rd— m'Ur-k fte,.maid am ct�l
R. it: .f
4.Date Well(s)Completed: WeIl
SR.Well Location: 10R. Sa
71 f f o. 1 1 ry\6— p Ke, 30 3 0
Racirwo.—N a facility IDo(ifapplicable) ft• ft' i __. r' s �4
D:'%3S Al C- 38 I1W1 1 OV�jb%Ar21 �1,C. :X-XS4
L
Physical Addtess.City,and Zip
(� 21.RRMARKS
County Parcel IdentifrtationNa.(PIN)
E
5b.Latitude and longitude in degreeshminutestseeonds or decimal degrees:
(if well field,one fat/long issuf5cient) 22.Certification:
3G9
I ' a-tl� N 2%0 1-1 W C\- -aa
6.Is(are)the well(s) Permanent or DTemporary SiguaWn dfCcrtificH Well Contracto Date
By signing this forma I hereby codify that the isell(s)urns Owe)constructed in accordmtce
7.is this a repair to an existing well: 0Yes or ON. ittith I5A NCAC 02C_0100 ar IRA NCAC 02C.0200 Bell Chrufmcdon Standards and rhar a
!forts is a repair,felt out known tvell construction information and explain the nature of the mpJ'of this record has been provided to ilia veil m+ner.
repair under 21 remarks section or on the back ofthisfotat
23.Site dingrant or additional well detatils: ,
8.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
corisGuction,only I GW-1 is needed Indicate TOTAL NU1vIBER of wells consttuction details. You may also attach additional pages if necessary.
drilled 1 (�j SUBMITTAL INSTRUCTIONS
9.Tots)well depth below land smfatx: (ft:) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulliple wells list all depths ifdifferent(example`3 r@200'and 2taJM eonsti Ilion to the following:
10.Static water level below top of casing: 30 (ft.) Division ofwater Resources,Information Processing Unit,
ifwater level is above casing use 1617 Mail Service Center,Raleigh,NC 276%4 1617
11.Borehole diameter: 24L For,Inie-don Wells:, In 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
I2.Well construction method:._Al r N QtOA r V construction to the following:
Ct a ouge.m►mY.cable.act push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (^ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Q Method of test: `S Atli$f-i 24c.For Water Sunift hc Injection Wells: In addition to sending the form to
the address(es) above, also submit:one copy of this form within 30 days of
13b.Disinfection type:_ - Amount: I b e. completion of well construction to the cotmty health department of the county
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