GW1--04971_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor information:
1`e.:Rr e.1 1 , S-t-ee,ei IA-f on 14.WATER ZONES - .
Well ContracterName ��MOM T(O DESCRIPTION,
(,
aLaa ASO ^C f(�-PM
NC Well Contractor Certification Number �� $ I ® P R
IS OUTEILCASING(formolli.casedwels)O LINER Ufa eable)
Stephenson's Well Drilling, Inc. ERoar TO DIAMETER T icMATERIAL' MATERIAL
CompanyName 0 ft: - b ft I/� m- s D N a/ /" V +Q
3 ®� 16.INNER CASING OR {ITUSIMG(geothermal d ,.• closed-loon) ' -
2.Well Construction Permit PROM TO DIAMETER THICKNESS MATERIAL
List all applicablenil Cantu angetnits(t.e.UIG Cormt}.Star Varhrce.ere) A A ft. ft. in.ft.
3.Well Use(check well use): / ft. In.
I Water Supply Well: 17.SCREEN
molt TO DIAMETER SLOT SIZE THICKNESS 4 MATERIAL
BAgricultural QMunicrpal1Publc /WA ft ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) rt. R. in.
IIlResidential Water Supply(shared) IS.GROUT
_!Irrigation FRtt'i I TO MATERIAL EMPLACEMENT MEIBOD�r3eSIOL f
Non-Water Supply Well: 0ft- ,a() ft- I?'Q-/l l tni�'v I O Lk( I 0 So IA belt''
Monitoring OGrouncry ft-
' ft CI pv
Injection Well: • /�r!
Aquifer Recharge Gmuadw.terRemrdiasirrs .
I9_SAND/GRAVELPACK ifepplicnble)
(DI Aquifer Storage and Recovery QlSalinity Border FROM 1 TO 1 MATERIAL EMPtACEItIENT METROD
Aquifer Test [�StormwaterDlainage f� .
Experimental Technology 5�hsidenc;Cast •
Geothermal(Closed Loop) QlTracer 20.DR1sLING LOG(echadditianal sheets ifnei:essary) ` -
FROM t TO DESCRIPTION(cob=birdness.saiurnd:type.min svr.d.)
Geothermal(Heating/Cooling Return) DOther(explain uader='21 Remo ) 0 It t / tr.#t 'lb,-PO_l : -
.1.Date Well(s)Completed:1-a.s `W3 wen 1DA-'. a. I Is--I . to Cjow .
5a.Well Location: 1,5 `t' 40 - -r fit/I.: -a ci t I
f'o,(Ai C(&rri vn Ctirri 1 Nrrl..f k-fO ' -aci.s t>; ('•oc [- , .
Facility/OwnerName Facility mg(ife\apbreb1) - IL ft 1"! I.•®l ' : , \
AIv(.r Brdokr R64.CiNcro-r-r frOrn 6rri J Oyfor 1 ft. ft. AUGhysical Address,City,and Tap al E,.s ft. ft _ . - H U tl I� ( .20ZJ
t 21:REtt8AERS r z-; e art3 ar,$.
CyrAnv l l/� ttIL.,. p
County Paivel Ident_ if n No_(PIN) D:D:LI '
5b_Latitude and longitude in degiees/minnte=lsecends or derinr 1 degrees:
(if welt field,one tat/long insufficient) 22.Certification: •
6.Is(are)the well(s) ermanent or Dremporary. Si �•dell Cttatractar Dare
m'aigaing this form,I hereby tsrliiP that the=11(4 ma(mere)constructed in accordance
7.1s this a repair to an existing well: DYes- or t" No -with L14I1'G4C D2C.0ID0 or ISA1VOIC QrC.Li00 Well Construction Standards and that a
If this is a repair,fill out!mama well auroral:Iran information and explain the nature of the colt"ofthisreeard has been provided to theuvIl owner-.
repair under Nil renttrrls section arm the backoft isfotar_
23.Site din oaoradditionalwelldPtnilr_
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the tiackof this page to pro vide:additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells consttuction`details_ You may also attach additional pages ifnecessaty.
drilled: 1 SUBMT3TAt INSTRUCTIONS
4.Total well depth below land surface: (ft) 24a.For All Wells:. Submit this form within 30 days of completion of well
For multiple wells list all depths iferffCrent(aamplc 3®200'and2 l00) construction to the followhit
1@.Static water level below top of casing: O c (ft) Division of Water Resources,Information Processing Unit,
Ifwarer leve1is tibave easing use"4-7 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: (in) 24b.For Iniection.Wells: In addition to sending the form to.the address in 24a
Q (� above also submit one copy'of this form.within 30 days of completion of well
12.Weli construction method: / t 1 r I I. C construction to the following
(ie-auger.rotary;cable,dheetpush,etc.)
Division of Water Rsaurces,Underground Injection Control Program,
FOR WAl I±7L SUPPLY WELTS ONLY: 1636Iiiail Service Center,Raleigh,IUC 27699-1636
13a.Yield(gpm) I a Method of test: Q.).-a(A5'Q' 24c.For Water Sunray&Inieccfiun Well.. In addition to sending the form to
the address(es) above, also submit one copy of this faun within 30 days of
136.Disinfection type: µ i H Amount: ib. completion of well construction to the county lientth department of the county