GW1--06385_Well Construction - GW1_20231002

I 1 I I •""
WELL CONSTRUCTI IN RECORD(dam 1) For Internal Use Only:
L Weli Contractor Information:
42,-c- r CI --r, Si elk Q,,1'b"C O N 14.WATEItZONES I !
Well Contractor Name 1 MOM TO DESCRIPTION
�4�a A Sap!t. 3ao IL GPM
4ZQ f tt10 f- , , GiN\
NC Well Contractor CertificationNtmuber
I5.OUT'Elt CASINO(Con atilt.-cased wells)O8 LINER(ifnpplitable)
Stephenson's Well Drillings Inc. FROM TO DCAM p THICKNESS 1 MATERIAL
Company Name C) ' O�\ ' (�,h/ hi- br\ : I D"C
3^ a�e�l 16.ZINERC.SINNOORT"JBJNO[(eeethermstdosed-loop) t V
2_Well Construction Permit# "\ PROM TO IHAMEratt 1 THICKNESS MATERIAL
List all applicable well cansiractionpermits(Le-UfC.County:Stag Variant;etc) N/A It. IL I. 'n'
3.Well Use(cheek well use): ft ft. I
in.
Water Supply Well: 17.SCRBEN , -
I'
FROM TO DIAMETER SLOTS= THICKNESS MATERIAL
Agricultural QhItmictpal/l=abtic Ai/A#t
it, is
Geothermal(Hratan5JCooling5upply) 42r1Residentjal Water-Supply(smglc) ft. in.
Industrial/Commercial. QlResidentiai Water Supply(shared) 18.GROUP • I
Irrigation FROM TO 1 MILT RSAL ' EStP CEMENTME HOD Cc AMOUNT Non-Water Supply Well: (1a l f IJ e,Ato 1 tte. Po u.- IIS®I1 bc\ r
Monitoring QRCCOVCry ft. ft. (�I- f
Injection Well: ft ft 1• 1
QAquiferRecharge OGroundciaterRem Lion
-
19_SAND/GRAVEL PACK tu applicable)
Aquifer Storage and Recovery Q1SarmityBattier FROM I TO I i<MATERLtL EMPLACE4iICRTtMETHOD
HAquifer Test QStmmwaterDrainage A/A R. ft.
ExperimentalTeclmology QfSabsideace.Centrol fr. fr.
°Geothermal(Closed Loop) °Tracer 20.DRILLING LOG fathehadtliticasi sheets ifae snry)ri
Geothermal(11eatiag(CoolingRetmn) QlOther(cxplain under=�2iRen2r'3a) FROM TO DESCRIEMONtc or.la��n sePJmrl:tyge,eninsize.etc.)
4.Date Well(s)Completed:c\`za-a3 Well I ! aV i
ells�,I,cAyC10�Se.Well Location: a� ft. S P�rO�h Sort y O j I
CC,n•.hr;d-CIGSsir. HoM /Sherror &1tates °\. `d5 Sa' frocIC 1 _
fL
Facility/Qwncr FacilityID,^',(ifawI,ahi:) R•
"I10I Sprin9Ackle, Dr. WaQ, Forest N.C, al PO ft. ft.
at. ft.
_.. d , f �3
Physical Address.City,and Zip ^It �1, q�i�/-t pr C• ° t�L!�'°"]_
Cr lanai t I�a4�00 I \ l O 1 b 21:1zarnanuuS f1
County • Fermi lde alnnNo.(PIN) 0 C T 0 , 2023
Sb.Latitude and longitude in degrees/mnutesIset:onrIs or decimal degrees: IC; ,=:.t-3.; ;..:j t"r.'r` ,
(if well field,one tat/long is sufficient) 22-Certification: C C.: : t7
36° ' 40" N —Ig° 34' 3`6" W t �1-144,40 ck-aa-as
6.Is(are)thewell(s) Persranent or °Temporary Si� � �5ficd Well Canatar Date
By signing this form,l hereby tenth that the-wrll(sJ was-(»j constructed in accordance
7.1s this a repair to an esis` g well: [Yes or 'No with 15A JJCAC 02C_o100 ar15ANCAC 02C.1L00 Wei/Construction Standards and that a
Ifthreisa Math;fill out known well construction information and explain the nature ofthe Jt3'ofthxr record liar been presided o the evil ownei_
repair under#21 remarks section oron the back ofthisfortm
23.Site diagram or additional Well details
8-For GeoprobelDPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTALNUiVMBER of wells construction details_You may also attach additional pages ifnecessary.
drilled: 4• SUBMITTAL INSTRUCTIONS
9.Total well depthbelow land surface: 3' O 6" ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For monde wells list all depths ft-eV-ere&(trample-3@200'(a_nd2@2100) construction to the following: '
`
10.Static water IeveI below top of casing: t4 (ft.) Division of Water RestimLees,Information Processing Unit,
If water level is above casing,use-T- 1617 Mail Service i enter,Raleigh,NC 27699-1617
11.Borehole diameter: ('rm.) 24b For Injection Wells: In addition to sending the farm to the address in 24a
Y above,also submit one copy of this R um within 30 days of completion of well
12.Well construction method: Air R 0 0.f construction to the following: I '
fie auger,rotary,cable,direct push,etc.)
Division of Water Resources,''Underground Injection Control Program,
FOR WAFER SUPPLY WELLS ONLY 1.636 Mall Service Centee,Raleiglt,NC 27699-1636
(� � i
13a.Yield(„•put) Method of test: l3 a A S ems~For Water Sunlrly Intec1 i Wells In addition to sending the form to
�j the address(es) above,also suhniitl one copy of this form within 30 days of
13b.Disinfection type: PITH Amount 1- lb. completion of well construction to the county health depattatent of the county