GW1--01714_Well Construction - GW1_20240315

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a,CONSTRUCT",N RECORD(GW 1 For Internal.Use Only.
I.Well Contractor information: i
�Se,+Cr�Ni 1 , St'49.1 \e,NSork 14.WATER ZONES I. •
Well ContractorNarc PROM TO DESCRIPTION
E0 ft- la! GPI"\
at-k P\ 1 -k0 H O i '( G P M
' NC Well Contractor CenifiationNnmber 15.OU ER CASING trot mnItlicrsed welts)OR LINER(ifa u able) •-
StephensOn%Well Drilling, Inc. FROM ' TO DIAMETER THICKNESS ss MATERIAL
ft. •a et. COI in. s bN ?Ni C.
Company Marne
������ 16 CASING ORT- IG(�thermaldosed-10ml -
2.Well Construction Permit#: );stOM TO DIAnEraft I THICKNESS MATERIAL
List all applicablensil ganstntr.don permits(Le.WC County.Stare.Variance etc) NIA in.
3.Well Use(check well use): // ft. in.
I Water Supply Well: 17.SCRE r - ._ ` . . -.
FROM I To MANLIER sum srzx THiCitess MATERIAL
Agricultural DMimicipal!Publc (� r. St. is 1 ry
(E Supply) Supply(single) v �y S .d SCh. t i 0 [ v
Geothermal eatin Cooling 1 Resitienhai�TJaFerS � It
j! Jim
IndustriaUComrncrciat Residential Water Supply(shared) C.
3S.GROIT£ II
Irrigation FROM 1 TO MA MATERIAL ` EMPLACE1ttEB.TbSte iNOD&AMOUNT
Non-WaterSupplyWell: t—�,, 0 Ira® ' 5efitoni ft ?oil r M Sc b by
Monitoring Et/Recovery - ft C j�.i
Injection Well:
i<: t€
AquifrrRecharae DGmuadwdxi.Remiliation
pAquiferRecovery 1]i m ty II 19re our Il1GlC vE1.PRt c(MXtEicaltle) _
Storage and Sal Barrier �tO1r 1 TO ! 1iATEZL#L EMPLACEMENT METHOD
Aquifer Test [�StomiwaterDtaioage >R t'
i
Experimental Technology t5ttbs* ceControl iL ft.
Geothermal(Closed Loop) facer 20.DRILLING LOG fattechad nna!sheetsffnr es) -
riGeothermat(Heating/Cooling Return) 1 lOther(explain under z'21 Remarks) FROM 1 TO I DrSCRtPT teator.L nln�sw'Jm 3 type.pia si�ctel
0a• 11 ' tosoi1
4_Date Well(s)Completed: DI•-ak Well DEW ' 1 ft. 1 0 ft- 'Su\4v1i hf d yl n
Sa.Weil Location: IQ R. Z f S'i` �/1_(�J0 r 0 C.1<
Ph-, IJ;r Is6-046 c.k ft.
, LR �,-- _
Facility/Otvncr Facility ID,.(ifs li ;ic) o' rt. I' S t L.Le j _i t j)t..1
/ ._ s Cc th _RA. Qs moor NS-. .e71 s-a ft I'' MA 1 ,+ 2UL4
Physical Address.City,and rip
21:REit7AR€£S:. - . , tftit rirt ;), .•
r n V /e x. ...s1.;e.:t
County Parcel IdeaiafitnNo_(PIN)
56.Latitude and longitude in degreesfminutes/seconds or decimal defies: 1.
(if well field,one let/long is sufficient) 22.Certification: j
rda ''-tt N —1 (NC) 4- , 31 W C '!, I t N1Q/N/J.IN" o_ai`a�
are the wells erntaneat or Teen Si55;���k -aBWell Contractor 0 Date
6.1s( ) ( - Pot
By signing this form,I hereby cert(that the well(s)was(werd constructed in accordance
7.Is this a repair to an axis'Vag well: Dyes or 4 10 nfth ISA 1C4C 02C_OM arISARUC 02C IL00 Well Construction Standards and that a
!fibisisa repair,jll out!most well construction information cad esplain the mere ofthe copy ofiii cord iws been provided to tIm well ocvner
tepairwidart?!rrlsarlasectioneronthebackoft isfaruL
l3.Site diagram or addtonal well drrtaiic-
S.For Geoprobe/DPT 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 details_You may also attach additional pages ifnecessary.
construction,only I GW i is needed. IndicateTOTALNUMB]:ItofweIIs ,.
drilled: /1,. SUSMFlTALlNSTRUCTIONS
9.Total well depth below land surface.: Lf-C W-) 24a.iTor All Webs: Subunit this form within 30 days of completion of well
Forum!pte wells list all depths i:Pr event(example-3QZOO'and 2031005 construction to the following:
10.Static water level below mp of engine: �� ) i
Division of Water`
Resources,information Processing'Ihri,
Ifwaterleuel is above casing,use't-" 1617 Mail Segvice Center,Raleigh,NC 27699-1617
13.13orehoIe diameter: (in) 24b.Por Infection Wells: In;addition to sending the form to the address in 24a
12. A Well construction method: . r Rota, Y above,also submit one copy of this form within 30 days of completion of well
construction to the following
lie.auger,rotary,cable,direct push,etc.)
Division of Water Resort ses,Underground Injection Control Program,
FOR WATER SUPPLY WELD ONLY: 1636 Mail Service Center,Raleigh,NC27694 1636
23a.Yield(;;Pm) I 0 Method of tee' 0.7(AU 1 24e.For Water Suntnly&Irkectiou Well= In addition to sending the form to
/I the address(es) above,also snhrait one copy of this form within 30 days of
13b.Disinfection type: _ I N Amour h t completion of wall construct tccon to the county health department of the county