GW1--05765_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
—5�' c-eN 1 . tS+etLe.rvl-On '• -14.WATER ZONES -I r -
WellConhactorName FROM TO DESCRIPTION
OLfaa A 15 ' '65 ' g. Cs PM
araSlt-. . ft: 176 C-�PM
NCth'ell Contractor Certification Numb ts 1S.OUTER CASING(formal6-easedwels)OZLEVER(If !foible) : • -
Stephensonts Well Drilling, Inc. FROM ' TO DIAMETER THICKNESS MATERIAL
Company Name 1') ft. -30 r- �11/A in- Sn1 \k p v Q.
3�a�s�� 16.INNERCASINGORTUUBING(gnthermatalaceddoup) : .
Z.Well Construction Perllutr'ir: FRO l TO DIAMETER THICKNESS 1WERtar _
List all applcablewell constt:tctianirataits(r c WC Corm Stare.Variattc�ere) A ft' ft. m"
3.Well Use(cheek well use): rt. lit. in.
'Water Supply Well:
FROM TO DIAMETER SLOTSTZEE TEl I1fAfEHIAL
HAgricultural EiI1 icipallFmbTic fr. ft, S n (+0
Geothermal satin Coo' Supply) t•.--Idential Waters (single) 0 � I n�,�dr O ` ry C.
� L1 � uPP)') � Supply it tit I is
]IndustriallCommercial II•�-dential Water Supply(shared) la GROUF : -
flhrigation _FRO:T TO MATERIAL EMPLACEMENT METHOD&AiaoircT_
Non-Water Supply Wen: . 0 ft. aQ SQ,thAde Pour U Salt) Iv),-_
Monitoring �Itecovc y #t: iG C h t p.r
Injection Well:
Aquifer Recharge OCaoundt:.eba Rentediatiea . _
19 S_ANDIGRA\TBLPACK(ifapplinble)
jjAquiferStorageandRecovery LJSaltinityBonnier FROM 1 TO 1 MATERIAL _IIMPLACEML•hTMErtiOD
Aquifer Test N/ R. Ft
Experimental Technology }�15[ormwaterBrainage
ISubsideace CattEol A a ;
Geothermal(Closed Loop) QiTracer ?0.DRILLING LOG(attach additionnIsseetsifnecessary) ..'
fGeothemtal(Heating/Cooling Retmm) QOther fecq: t under z'21 Remarks) Fmm TO Dec aci?TION t�atot„ttne-� v�actsae'ata I;zn aC)
%_ 0 fL 1 f J OP�'0•t/ -
4.Date Wells)C• ompleted: �''a Well IDS / f t ^�d n' , Fir(�0 W�hr•rq \l .`101:./ .
5a.WellLocation: . - .q0 • irL Q�.5d JG�1a o C ( . -
rr r•,c.k- i�tI •P;I sfro r -
Facility/EicvncrNarac Facility IDll(Ifapptt lc) ft. ft: ; ,,.
313s 6ro9cAer1 Rd/ S -e,r,/N,C, a� S-.7\ ft. , :C.•0 ` EE r .
Physical Addnas,City,and Zip it. ft. f - - 3
CI ro,nv�/l�. 0%lc%o3 LH-ICE%I -i;Fr�AtP s- •
•
County .. Parcel ldct;ncatina No.(PIN) Irt(6Tifv'.aivtfl Pro:c6 ai:: lira
DSO+`; r OG .
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
•
Orwell field,one Tat/long is sufficient) , 22.Certification:
3 ° I i o " N. -ic6° 4-a' s 7s " W
_ - -- ---6.Is(are)thewell(s)Permanent: or QTemporarJ Sly,: o'►-:,, LVcllCaatractor Date
By signing this Sam I hereby certify that the uell(s)was(Isere)caastntcted in accordance
7.Is this a repair to an existing well: {JYes or No -with 15A 1JCAC 02C_0100 er ISE JPC4C 02C MOO llls7 Construction Standards and that a
• !Phis is a repair fdl out known well construction infornation and explain the nature ofrhe Copt'ofthi'a record has been provided to the-ell owner.
repair under#21 reawrfasection oron the back ofthisform.
23.Site diagram or additional wail detail':
S.For Geoprobe1DPT 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 1GW tisneeded. Indicate TOTALNUbdBERofwells constructiondatails_You may also attach additional pages ifneaessary.
- drilled. 1 SUBMITTAL INISTRUCTIONS
9.TotaI well depth below land sur;'ace: a ( ) 242.For All Wells: Submit this form within 30 days of completion of well
Forum/tore tear list all depths ifdrfferent(erampho-3Q200'and 3Q100) tnnstmction to the foIlowini
10.Static water IeveI below top of easing: (ft.) Division of GtraterResources,Information Processing Unit,
ifwaterlevel it above easni use 4--. 1617 Mai/Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: t1 Can.) 24b.For Injection Well=I In addition to sending the foam to the address in 24a
IZ:Welf conshvctibn method: Air R otR r y above,also submit one copy Of this foam within 30 days of completion of well
construction to the following;
mew,•
Division of Water Resources,linder'vound Injection Control Pror,r am,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Ser ice Center,Raleigh,NC 27699-1636
' 13a.Yield(ggptn) J o Method of test: V A in,D' ' 24c.For Water Slimily&Yitieetion We is In addition to sending the form to
/ the addresses) above, also submit one copy Of this form Within 30 days of
13b_Disinfection type: f l T r'7 Amon=i I b. completion of well cans i ct?on to the comity health department of the county