GW1--04969_Well Construction - GW1_20230807

0 .
WELL CONSTRUCTION RECORD(GW t) For InternalUse Only: '
1.Well Contractor information:
�4QJci-`12,1/ 1 , 5+e hp. s tor% •14.WATER ZONES . :- '. - .
Well ContractorNamet FROM TO DESCRIPTION
`sots. i INnft. I°k0 tic
i - -3SP/\ ..
ft. It.
NC Well Contractor CertiSrationAlmaber LS m O1JTER CASING far inn-cased welts)OR LINER Of ..'.:,el
Stephenson°s Well Drilling, Inc. FROM ' TO Dicta Talmo• MATERIAL
CompanyName (('' ��`` I 0 ft. a% 't _ l�'�Y m. S n PI,D ! V'C.
�O 4 ' ! 16.INNERCASING ORTUSINIG feeot ermsl Closed-long)
2.Well Construction Permit#: _FRO TO IHAI[IEiER L.THICKNESS MATERIAL
List all applicable null canstrrrricovenuitsfie,Ulc Cotmty.Stale.Yariaffre.etc) / - in.
3.Well Use(clieckwell use): - . A. i .
I Water Supply Well: :17.SCREEN -: - -
Mom• To DIAMETER SLOT SIM THICKNESS MATERIAL
Agricultural 9MuniclitaliPublic /VPift" it.
-Geothermal(HcatmelConlirZSupply) .Rcsid»Ii21 Water Supply(single) ft; p� ;n
IndustriallCommercial • ntResidential Water Supply(shared) 1�GROUT
litigation PROM ' TO i }Gi�f33EftZM. ' L�li iPLACFi1�[17TrIai 11iOD& llatL�r(
NonWaterSupplyWell: Oft- a ft: I �=fit )t poVlr: I J S 0 H I�,gJ
MonitoringRecovery £r. ft: C !p`r
Injection Well: ft.
t
Aquifer q a i9_S_ANDIG`R4'i'EL3 .CttC(i npplt�Ieh -
AquiferStorag and Recovery Q15a}n,ilyBurner FROM ,,TO StATItLtL _E\IFIACE51C,1rssEITIOD '
Aquifer Test [IlStormwaterDlainage •
n/ �q R R
Experimental Technology OSubsidence Control
.Geothermal(Closed Loop) J Tracer } 2t).DRD.LDIGLOG(att`e additional ifneecsar;) .
fjGeothermal(Heating/Cooling Return) QOther(explainuader-21 Remarks) I Irami To DrS.CRI?Tlox tmks-.h-.t e,ur time.e�:� etc-)
t r! ft; 1 . Id' -, . TOiCt-r.0.,) '-. : . . . „
Q.Date Wells)Completed:. "a 4-a3 'Well 11 I O• lo rR. ! 1 of r c/l I: c,W n se.soi 1
Se.Well Location: I .Ia. ff.:: 3.a-J-. '. ..: P D e,k , . .
AiAc.r. Curry CurrIA,F0.rtvw7 •
Facility/Owner Name • • Facility-Mg(ii-r 1^:_) It. • .fi., 'Ld�" '( r,..`-.'.
Vill'O• -fa/N.. Pck1 J4l/oc..!< N, Q. a-, So, . ft. ...
PhysicalAddtcs.City'andZrp ._.,.z. ft
.. `.. R b 0i Z023
1/kt✓ l V a (C) 3 a3 l t I-\ .IL.
ltEW1ARTGC.: . . . ai, 3..-,-�`tsY',g t;rli
County Par clldendncailonNo.(PIN) . f)I rld'ia"1;
513.Latitude and longitude in dogreeslminute=lseconds or decimal degrees: .. _ •
-
(ifwell field,one tat/long is sufficient) o v/ ,I ••22:Certification:
•
6.1s(are)thevell(s) _ermanent or rerr porary
Sid (: ...fic4Wcil Connaetor'7 Date
• By suing this farm.I lterehy cert fy that the riell(l)scar(acre)caiarructed in-accordance
7 Is this a.repair to an eskary well: Iles or4,0Na melt/5A.l C.4C.02C_0100 or 15A NC4C MC map Wel/Com-mid/O StardQrrl,,d that a
co a thisrecundharbeen Provided to ther7-116=er__ '
Iftlricssarepair,fill out kaotal tsztI cottmrtcrirtn information and t�rlcwt the raturtaftlte P3'f Fes' :..
repair under#21 retuarissection aron the back ofthisfors -
73.Site diagree/or additional well details_ .
8_For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use:the back of this page to provide additional well she details or well
• - construction,only 1 OW-1 is needed..Indicate TOTALNUMBER of wells construction'detatls:.You may also attach additional pages ifnecessary_ •
•
drilled - SUBMITTAL It3STRuC IONS - -
9.ForTotal well deptIa below land surface: 3 a 5 -• (.ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For ntltiple wpIls list all depths Oil-gnat:(example-3®200'arm 12 100) construction to the following
•
S.
I0.Static water level below top of casing: (t ) . Division of gate-Resoneces,Information Processing Unit,
Ifwaterievel is above casks use-4-7 • 1617 Mail Service Center,Raleigh,NC 27699-1617
Il_BorehoIe diameter: (in) 24b.)For Injection Wells: In addition to sending the forn to the address in 24a
^ /� above;also•;submit else copy-of this form within 30.days of eons lletion of well
12.Well construction method: , Air_r 1'1 o to r y construction to the following:. ... - - •. . .
Cie uuec,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(pm) 3 . • Method oft : &Q in)e- 24t.For Wawa-Sonuly Er Iniectih..n Wells: In addition.to sending the form to
• �{ / the address(es) above,also subunit one copy of this form within 30 days of
13b.Disinfection type: 1 ' TH tJ Amount: l b . completion of well construction to the county health department of the county