_Well Construction - GW1_20230310 (39)

V
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I,,
3 L4 c e.\1I \ .. l sie.p1\ 1'\SO l
Well Contractor Name 1 FROM TO DESCRIPTION tt'\
tk5,ft utt.0rw It CSPPIN
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ltcable)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. c:::::(Tft. Sl/ in. S .al Pv�
Company Name 16.INNER CASING OR TUBING(eo ®(�
tLermal closed-loop)
2.Well Construction Permit#: 3%Lk 4 a 5 FROM TO DIAMETER TRICIOvrSS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) AI` R. ft. 16'
1 ft• it. b'=
3.Well Use(check well use): ;.s i
Water Supply Well: 17.SCREEN-. I'
DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public N/A it.
ft.
Geothermal(Iicating/Cooling Supply) Residential Water Supply(single) it ft. in.
IndustrialCommercial DResidential Water Supply(shared) FROM TO
18.GROUT
IrrigationFRO!! TO {MATERIAL u- EMPLACEMENT METHOD
Non-Water Supply Well: ft, t�\y ft- I Jl�n d/`l7ir. Pour r SO lb .b .1—
Monitoring [_}Recovery ft ft Chip.,
19 SAND/GRAVEL PACK'(ifappl cable)
Injection Well: ft. .
Aquifer Recharge DGroundwaterRemediation
Aquifer Storage and Recovery Salinity Barrier FRo To MATERIAL EMPLACEMENT METHOD
Aquifer Test QlStoumwater Drainage //f} it2
Experimental Technology f jSubsidence Control 'v ft. -
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness.sontrock type.eras size.eta))
Cj ft. I j oP ro
4.Date Well(s)Completed:a-a. -as Well ID# / ft. Q_Q ft. ' Re.dt C lg\y 5a.Well Location: aci ft. S, ft' v)C o v ► .S'eA re,
VAIK r RiAiitile.f.r I /SkeXron f_s`tate.s Lot IS 5 ft. 5% ft c‘C.,l<
Facility/Owner Name Facility IDe(if applicable) rt. ft. 'i^ \ '7 7•
3°I1I SaSe. CA", WL•Ke. Fore.J''t !VAC. Q 1S-T1 ft. ft. �. •.. .....er ....._::r'
Physical Addre
ss,City,and Zip - ft. f MA` 2023
CTro rvl tie, Isca1/4t40 Lk0�(,\VI 21.REARKS
lir...a: ,1 '. (er a
Parcel Identification No.(PIN) r , �~
County ____
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ( 22.Certification:
3 ° 3' )S r' N �(�j 60 3 LT ' L*3" W ,
6.Is(are)the wells) Permanent or Temporary Si rr it' Cc Well Contra r Date
v By signing this form.I hereby certify that the Kell(s)itins(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JNo with 15A NCAC 02C_0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information d explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary_
dulled: 1- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: gCo S ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a1200'and 20100) construction to the following-
10.Static water level below top of casing: 3 3 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail S Iervice Center,Raleigh,NC 27699-1617
U.Borehole diameter. rm•) 24b.For Injection 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
12.Well construction method: t r Pl� 1 o.r y construction to the following
(Le.auger,rotary,cable,direct push,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: G c (&S Q. 24c.For Water Supply&Injection Wells: In addition to sending the form to
J
1- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1-1 T/_I Amount: -1- lb.. completion of well construction to the county health department of the county
where constructed_
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016