GW1--07831_Well Construction - GW1_20231208

WEIL CONSTRUCTION RECORD(GW 3} For Internalise Only. i
I.Well Contractor Information: -
•
W,llContracterName num TO . DESCRIPTION
asc-D.a /N° Ino 1-0 t la.Q CIQM
NC Welt Contractor Certification Number •
yr,OUTER ((for multi-cased walls)OR LINER(f•Male)
Stephenson's Well Drilling. Inc. FROM 1 TO ' prio MATER
Companyxame clft' Cic 4 fLCu1 in. S nR 0.1 - PVC, -
��� 16.IT+NERCASIN OTUDIDN (Ootherahalelmmgl o0' .' .
2.Well Construction Pesnriti: IR TO , Dt TSICOA S MATERIAL
List all applicable on!! peratirs(Le:UIG sr: :�Varian=eta) N ft ft. ta.
3.Welt Use(abed/well rise):rise): ft. €t: i in.
Water Supply Well: 11.SCRI 1
FROM TO DIAMETER SLOTS .s TMCIOMTE M ranTAY.
• Agricaltinal IjMunicipal/Pnb1e ^/hi a. ft. ; in-
Geothermal(Hcating✓CoolingStrpply) .�IResidential WatnrSupply(smgle) f tr. ' R. I in.
IndustriaUCommercial QQResidcntial Water supply(shared) t la. t®tTr • . • -
_ FROM TO MATERIAL .' E&1RIAf t1' !Estee O rrivr r_gNilnination
on:Minter Supply Wells __ 0 & aO ft: Be.n`tO ni fe. j'Qck r 1 S, ,S Q 11 1=5_
Monitoring QRCcovcry It. ft. c h
Injection Welk
Recbarge QGmundwaterReaediatica fie IL-
golfer
Aquifer 9toraee and Recovery QDSalinity Ba.ia. IR�BANOI�HfiV EAC MAATER/%Ie)
a FROM TO ti4AEER7tiI. EMPLACEMENT'
JAquiferTest Q1SroimwaaterDrahi ge N a- ft. a. :
1eamenlalTecimology Snbthrl e Capp. / f. 1 ft. •
Geothermal-(Closed Loop) QTr: ' 20.DIi�L DIMING additionalb sher ri l -
Geothemial'(Heating/Cooling Return) f Other(e plainnnrt4ml.Reaaaaks) Boa Tro D7at arac s' �)
•
' a f� I. $ . `rop sn, 1
4.Date Wells)Complctedi 1 l.2 a3 well I st ao . I Sa„ s r .d1 dm/
Sn.Well Location: ac) n' CI ' 14 ::'SAta
Cilr1./ 9 Corric Wilson — V ' I1..s"$. ' ' Noe.,l( _
Facility/OavncrNama Faciihyl'Ir f€[zfapprm hic) - ' ' i _
C3�1-1 r K 3- lei r\cam'o..st F ► N e,r o f rd r% �'l1"3'1 fr. _ _ ' ' �„>' a•�'
PhysipIAddrem My.=dri t • ft. • fr. ' : DEC 0 R 2923 .
/ _� 21.R 141ARMS
Yin C-�. . . int.Dtir..: ^rt Win_.._.
County Parcel ldemif latinallo(PIN) i f' -`it,::] i 10
Sb.Latitude mad loogitardei t degromfrakastesfsecandssirdet
(ifwell Sold,ono'lauzang is sufficient) 2�
3 6° do l L(-(41/ N .1 0 3a I i t . W k .1.1, \,,.jj��
_.6.1s(are)thewell(s) ermanene .QTemporary si•__,'"
. •." ..�vcllContraeur
tysiguicg r l5iaa;lliniiki caitifp�`timr the u ica; .ca.-zstrricted la accardmice
7.Is thisai pair to nn el gavel&'dr
Oyes or 47Sio lath 15A NOW f1CA1OO c147A 111CfCO2C.tallO Will Cam StmrtkircTs and that a
. Ifrlusisarepafr.jill out bate?well cmttaucttonarrformatian and apfma the nawreoftbe cola'alrlwreanriiharbxaprdvld dtodetcerlaw :.'• -
repair under#21 remarks section arm the baekofditrfarct
23.Site dhsgiaeor additional well deten
0.For Geoprobe/DPT or Closed Loop Geothermal Wells having the k you may use the ha of this page to provide additional Well'site'details or well
construction,only 1 GW-1 isneeded. Indicate TUTALNUIVlBERofwells . coastlirctiORdetali.Youniayalso altachadditionalpagesifnecessaty.
drilled:
sE1BIVIl3`ifA]L Il�T5IR1UCl IOIaIS
9.Total ildegttla below land surface:. U Qom) 7a. o L - . .
Formultpiewellslista!(depthsrdeermrt(example-3 firand2@illY) �—I a�0 5ubugtt this fame within 34 days of completion of well
J/ co»stmctioa to the following •.
10_Static tivaterlevel be%vtmpofeasing: ) Davisionoff rater unreel,InformationFrneestingUnit,•
Ifwa erlevetts abateeasing„use-a-- 1617 P/dail Service Center,Raleigh,NC27699-3617
IL Borehole diiamete,0 241R Xor linjeet on Welts: In addition to sending the fo m to•tbe;address in 24a
12.Well construction method: PI I r f\O±O r above,also.submit one copy of this form within 30 days of completion of well
-(i.e.augcr,mtary,cable;dime:push,etc.) COnstiIICtian to the foilowingi
I'
Drumria.o€Wat rResources,ZTsv..as racurd' ea oaCont olPirogem,
FOR WPs"ER5itl?Y3,`1'WELLS 01\11.4: •,16351V1aiService Center,R .27699-1636 '. .
13a.Yield(g(tat) ao Method of tests C O U g�• 24c.For'sfiater Sop Io 8c iCrtiei lion Jells:.Ina`add tioa to sending the form to
the address(es)above.aisol submit we copy'elf this form vrtthiti-30 days of
13b.Disinfection type: �7 T a Amoana i_ 10 r completion of well construction to the county' eatth department of the county