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Home My WebLink AboutGW1--06441_Well Construction - GW1_20231002 e ►A his CONSTRUCTION RECORD(GW f) For lnternalUse Only: 1.Well Contractor Information: ' �Q., ° rey ‘ . Sie f "ex\S=0 r, . 34.. rATE S • t t . . WWI CoalractcrN 4R®bi TO DESCRIPTION ��aa _A .ac o .�%on- 11 CPC ft. ft. I NC Well Contractor Cenification Number t5 OUTER CASING(for multa-cnsedwells)OR LINER(ifimplicablel Stephenson°s Well Drilling, Inc. y women I MOO 1 MATERIAL C 1' e-14�TO fL I NIit �- IS oN at Pv Z, 26.DTNERC.ASIi+hG OR.TUBING Ceder ermul used-foupl .- 2.Well Construction Permit& CTw 1C'l'e''S"11 -- aQ a 3 FROM TO DIMMER _ MIICKNESS a91aTFRIAr- List all applicable uelIcontirzalarzpenults(i.e.(ftC Cowry.tint l'a,a1„L..era.) /VA • - ft. IL' It. I in. 3.Well Use(checkwAl use): 113/ater Supply Well: FROM SCREEN • • - - :ROM j TO I DIAMETER. sti3rm= iinativ'ES5 I mximum. Agticulttttal ii-,,.;-> !ttbla; �/A It I ft, I tau. 1 Geothermal(IiratindennI-m`Supply) r4-:rsidrntial WatnrSopply( gle'J I rt. j ;'L t f Industrial/Commercial DRtsidential Water Supply(shared) IP.GROUT t ; t 1 irrigation 'I saux I TO I 1 E FLAG 1_7N DIE1EOD& ztonNr_ 1 Non-Water Supply;dfell: 1 0 fr.1 ta0 ft. )CIAO At.h. PO kit (L} SQ ii, lugs- - (Monitoring - - • ttRccovory Ift. I ft; C. x Injection Well: fc. 1 l� iAquiiferRecharge EIl,-n-rn- l-- ?�-�s=t� a, r - s9.-SA'�DIML'zl F.L—PA of n1cs anlel AquiferStacu a and Reeu.ccy QSalititp.Earzle I mom - t MATERIAL 'mart.ACE4tnivraiEruon _ Aquifer Test DStormvraterDr. s lIN A & Iit. I FacpedmentaiTechz alogr S, aecaC't - $ i I I I Geothermal(ClosedEoop) ram— I 2:FJMIa 's{{IGt tzea:aidlEan_3abmbffr r $) - Geothennal(Heating/CoolingRetain) DOther(-zplakundm-t21P ni) PRQn 1 O I Di t2IFcto:aces.11-.I=a m';Ttrmrt;413e,2r,t2lizg.act 4_hate Weil(s)Completed: O a:k"e C J Well Mg, I t1 /Jo R' 1 1: ( r cL SPJnIly f O 11 _ 5a.Well Location: 1 I" it. 43 s !:w-okkliZ �0.— 7 77 .r0_t I OsceAr �(o‘rin `h3 P- (S5n: Nod.< - - raciliwiCtenerNamc ^17T,iiirEn'^.) 7 / ft' 13311 Creeckmoor Rok. 11 49., 01-zlais'i1 ft ft. r_ �,, ;m r-) . PhysicatAddres.Cir„aadZap '`3. � f ,..,-�...r rs.',i Er its. ,, Woke- a��aa�.00 �g "R . - 3 County - Parcel Id'ntirrtmn No_(PTl) info; i^.R i3-.7.1"'":=,2 Ur.:a Sb.Latitude and longitude in de es Orin fseeondr or dertrrni degr " �'•U::. ti. (ifwell field,one lat long is sufficient) 22.Certil cotton'. ' 3S° Q ' 3 3°' N — 6° 14l ' 111/ W A` j, 1 a -a3 .s are the-weIl s ermtament or i orara Si a .r. Vdi Cont acm . - Date- Y By sikehig tkis fatot I hezeby ccrtifr that rbe uall(r -as(aum1 carutracred in accordance 7.ls this a remit-M n-e: ; ells Dyes or&No red?.Ii 1 Cf2CJ11grA-I�s7C4C1 C../R0 t WNll Canctructioa Srmatenir end tlun a this Lsarel hfiIhradzms =llmmun7 ;,.., as emplalstkeJ mosrae Ye17rszeorneh-shemPrarir?egtothea:I7at--1-. repair under:21 rrnuvaaectian or an&a ba�afra-for - 23.Size dingam.or adduana'wen e1 5Ir 8.For Ceoprobe!DPT or Closed-Loop GeothermalWells having the same You may use the Lack Of this page to provide additional well site details or well construction,only 1 OW--1 is needed. IndicateTOTALNUMBER ofwells const:diction detailt_You may also attach additional pages ifnecessary, drilled: 1 sumaTTAL INSTRUCTIONS 9.Total well depth below land surface: V Ql. 0 (ate) 24a.For All Wells: Submit this form within 30 days-of completion of well For multiple wells list all depths ifdtjfetrnt(rumple-3(2OO'and2@IOD) construction to theioliowini 10.5'3i tic tivatet level below top of casing: j (t ) "MUM of Water Resources,Information Process-mg Unit, Ifutuerlevet is above easing use-" 1617 Mil Service center,RaIeiigh,NC 29699-1617 IL Borehole(Hameter: (in-) 24b.For Injection Wells: In addition to sending the form to the address in 24a 12.Well construction method- I r 11Qt� / above,also submit one copy of this form-within 30 days of completion of well (ne.auser,rotary,cable,direct push,etc.) construction to the fotItiwirtg Division of Water Resom es,lindergrornosliniection Control Program, FOR WATER.SUPPLY ONLY: 1636 Mail SLT4ice Center,Raleigh,NC2i6991636. 13a.5tieid(gun) I Method�f Cso ti)e.. 24c.For War Sutmiv Er Inie+ n Wei In atidittoa to sending the form to H the addn (s)above,Alacnlrnit one copy of this foie within 30 days of 13b.D./Shafer-lien type: Ii 1 Amount: I lb a completion of wall�tstrirction to the county health department of the county