GW1--02245_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD(GW 4) For Internal Uss Only.
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1.Welt Contractor Information: .
Q. T, -S`-2�1n"�e,rvr o rN 14.Wa�ZO� - '
Well conhaetarNatae1 FROM TO _ . _ DESCRIPTION
3%0� . %0 it. . cy r n
NC Wen Contractor CcttiffcatioaMather L5.OUTER CASING(far rtpliicesed wells)OR LINER(11 IIcable)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER TRIMNESS MATER/AL
Company Name v f fL C1fcx in. Sbv,a1 ` Q
3� 0� ' 16.DINER CASING OR TIMING fi st wp)4o
2.Well Construction Permits: % FROM To DUAMEa'ER TRIMNESS MATE tar.
List all applicable well canslnrctiaaphaatits(Le.UIC Count.Stag Variancr.etc) 1°/L IL
3.Well Use(cheek well nse):
Water Supply Well:
Agricultural It IVInnicipal/Poblic
Z7.SCREEN
FROM TQ DIMMER StaTSiZT TfCFO S 1vzATEn3AL
ei
AIM tL ID.Geothermal(Flcaffig/CoolingSupply) iResidential Water Supply(single) Y� ft. ia,
IndustriallCommercial
irrigation
III Residential WsterSupply(shared) a3.Gt2®o c ..
- PROM S9ATiiRF1lL F71rFfACE TM R0DdiAiitotavr
[Yon-Wales Supply Well: 0 it a() fL �gfti jn 1` `2, ?Qkr 11 Sc)i 4 be r
•
Monitoring �IRccovcsy C..1)Pr
Injection Welk ft. 0
Aquifer Recharge DGtattntloraterRemediation
ft.
l9:SAND/GRAY PACT(¢Ianplienble)
Aquifer Storage and Recovery DSalinity Battier FROM TO MATERIAr. Edrt LACFhtE!•TMTrgOD
s Aquifer Test OStormwaterDtaiurage n f ft.
Technology �lsnbsidence Control -
Geothermal(Closed Loop) �ITracet ' , • 20.DR1LLIIVG LOG(anal'add/Unitat deetsif amatory) - -::•',
Geothermal(Heating/CoolingRetum) DOther(osplainunder"2 MOM To D m tardozo.mUtrarktrce. insiaetc.)1 Remarks) ry
.. I . , ..:-I-.QPc 1 I -- _
4.Date Welts)Cotlapleted:Js V IUt• a' .Well MP . - /. IL. I 0 it : ; NA - C 1Aj f
sa.V/ellLoeation: • 10' t. '-:l'c) $ t? CQ]N N- 'fa 11 �.
Cav;k"ier2, (�or"e,.r -S'hedr F:�r`ro�. tc..ie4 .J -t� ftQs'$. 5 ' 7.06i( . . . - .
Facility OivnerName Fe«ibgr3a(iE pli-.€sac) : • , - .. — _
(120 S'Pr,r*(Q, b 1 \c.Kt Fore,.rt N C, 0aiS 1 - V t1
Physical Address,City.and rip p�, n p�G ft. ft. • - APR t) $ 2 0 24.. -
V rd`ry l l t Q ' Da V V r l_i 1 21.R�'M_A . ` • -
Parcel idcatiftca ionNa(PIN) t n i::r i, '" '._•-,E;n 1) '
County % at ✓✓� ..
Sb.Latitude and longitude in degrees! mates/sr*rtnric or dectauai domes: - .. • . . .
(ifwall field,one lat/loag is sufficient) 22.Cesl satit3zi: .
6.1s(are)the well(s) la ermat+ettt or.DTemporary -_ Si o led c Caturdemr Dam ' •
.
��// By sig Wag ddr farm,I berehy.ara1.that the well(s)nos(iwere)constructed in accordance
7.Is this a repair to an existing well: fairs or o nith/IdNCACO2C_OI00 Or I5A IYCAC MC MOO Weil Camrnrcnmi Siandards and Thar a
. yeas is a repair.fill ourlamwar well can tneatau infomratiauandexp mr is the nature of tier cPJ'oft/usrecordlmsbeen provided to thew ellowner- ' - .
mar underi Zl remarlasrrtian or on the book aftlusfomr 23.Site diagram or addidenal well detailsi •
8.For GeoprobelDP T or Closed-Loop Geothermal Wells having the same . ' You may use the back of this page to provide additional well site details or well
' constnrction,only 1GW-1is needed. Indicate TOTALNUMBERofweils constmctiondeiails Youmayalsoattachadditionalpagesii'necessary.
drilled: 5d( I'Ala E14ignauCZ'I®):IS .
9.Totalwell depth belowlandsurface: �/ - (I) 24a,For-AI*dist. Subs this thin 30 days of completion of well
For multtple wells rir1alI depths trerjjermt(eample-3(a? arco MOO') construction to thefollowin
10.Statie water level below top of casing: 3 5 (t ) Division of Wate.Resources,linfornntion Pp prn:ctn$Unit,.
&water/eve/Is abate ensibg:use"t-- 1617 Mail Servlee Center,Raleigh,NC27699-1617
11.Borehole diameter: (nt.) 24k.For inieetion Wells:t In addition to sending the form:to the address in 24a
f' 1 .. above,also submit one copyy of-this form gitthia.330 days of completion of well
f 2.WeIl construction method: I f l0 1- r y to the following •
(le.auger,rotary,cable,diirectpush,etc.) . •. -'
_ Divisionof Water Resources,Undergroundd-Injectiou Cootrol-Program,
FOR WATER Stli'1'LY WEI IS ONLY: 1636 Mail Service Center,Raleigb,2YC 21699-1636'
13a.Yield(gpm) a Method of `l'��S e) 24c.For Water Supply&Infection Wel hi addition to sending alit:•farm to
I"I1 the address(es) above. also s brit one copy of this fart within 30.days of
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13b.Disinfection type; I ► I Amount: ca 1DJ t completion of well eanstiuc i=to the county health department of.the county