GW1-2023-01045_Well Construction - GW1_20230125

WELL CONSTRUCTION RECORD(GW--1) For Intemal Use Only:
1.Well contractor information: L
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FROM TO DESCRIPTION
Well Contractor
j�onnttractorName it. fL
Lk
NC Well Contractor Cenificatioa Number 15.OUTER CASING for mNti-ea w weIlc OR MER d li a t�ble
Stephensonis Well Drilling, Inc. FROM ToI DUMUM TMCKNM MATERIAL
ft. rr. Si. in. sop 11 P V C
Company Name Q' 16 INNERCASING'ORTUBING( "therinddosed400r
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2.Well Construction Permit#: 3 ` ` o FROM I TO DIAMETER THIC avM MnT;F UAL "
List all applicable'veil conslractionpermits(e.UlC,Count}:State Variance,etc) ft tn.
3.Well Use(check.well use): IL !c in.
Water Supply wen: 17.SCREEN . .• _;
FROM TO DIAMETER sLo'rsin TBICttICESS MATERIAL
Agricultural [3MunicipaliPublic n Mf �-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) IIt. ft ;o
IndustriaUCommctnial OResidenttal Water Supply(shared) M GROUT ..
hTi ti0n FROM TO MATERIAL EMPr.AMUNTDWMOD&AMOUNT
Non-Water Supply Well: 13 ft ft- ,4 e, Jcv r A 5-01 be\
- Monitoring ORecovety fL M
Injection Well: ft �
Aquifer Recharge [Groundwater Remediation
19:SAND/GRAVEL'PACK rf i► licable
Aquifer Storage and Recovery QlSalinityBarrier FROM TO MATERLII I EMPLACE6iEhThlETfiOD
i Aquifer Test OStormwater Drainage AdAD•
Experimental Technology OSubsidence Control ft- ft
Geothermal(Closed Loop) OTracer 20.DRII:I:ING LOG attach additional sheets if necess
R
Geothermal(Heating/Cooling Return) ` Other(explain under#21 Remarks) FROM To DESCRIPTION color barons,,soIDro& sac.eta
D• To pi
4.Date Well(s)Completed:. ' 3 Well M# R' R' ' @, I P-61
Sa.Well Location: R• t ��it ®C
ft ft .I
Facility/OwnerN a Facility M#(ifapplicabte) R' R'
�. 21 S C.1 ft. ft. JAN 2 51023,-5� - croryeAt ya'-nn M� sAPIM
Physical Adddres,City,and Zip R• 1t �^- ,�3ySv^�pt'i^.c?i DiF:J vo
UR.t
Cs l �lnV 1z 21.REMARKS. .. J�4dQf
County
Parcel IdentificationNo.(PIN) f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcil field,one lat/longis sufficient) 22.Certification:
N LE�.� . ti W
�` w� 1-IL-a3
6.7s(are)the well(s)PPermanent or Temporary Si cd Well Con6ac r Date
,,77 By signing this farm.I hereby certify that the iveR(s)inns(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or�NO ufth 15ANCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Phis is a repair,fdl out known well construction information and ezplatn the nature ofthe �FJ'ojthis record has been provided fa die rvellowner.
repair under 1r21 remarks section or on die back ofthisform.
23.Site diagram or additional well details:
8.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 OW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: 1 SUBMITTALS
9.Total well depth below land surface: ��� I;
p 24a. For All Wells; Submit this form within 30 days of completion of well
For multiple we&list all depths ifdtfjerenf(example-3@200'and 2@I001 construction to the followin I
10.Static water level below top of casing: (ft) Division of Water'Resources,Information Processing Unit,
Ifwater level is above casing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: (m) 24b.For Iniection Wells:j1n 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: 1 r Ruler I construction to the following
(ie,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sirvice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: '��A 24c.For Water Supply al:Injection Wells: In addition to sending the farm to
_ the address(es) above, submit one copy of this form within 30 days of
13b.Disinfection type: ( Amount: 1. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environtaental Quality-Division of water Resources Revised 2 22 2016