GW1--02246_Well Construction - GW1_20240409

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WELL CONSTRUCTION RECORD D(GW ) For Internal Use Only.
1.Well Contractor Information:
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iaRc-R y 'T Sieik e,rn .s 0\ IC WATIIIMPIB.S I
Well Contn..etarName J mtOAa 3O DFSCPButION
`� a�: A 3.'►O� a o /� csPP\ .
NC Well con rceitificnion Nwnb IS.OMER CASING(re multi:-ccsed wens)ORLEI I Of Ucib1e
Stephenson's Welt®riding, Inc. IROM TO ' MUSTERT !C atATEt3tat.
Company Nome � Z) IL 1 V g G i/td� �_S© ' V Q at L
�o t f J r Q\ 36.iPR�tE1tCAsSHi�IGOY3MIt+tG.ff mad 4000
2.Well Construction Permit#: IR TO _DIAMETER TRIMNESS _'MEDIAL
List all applicable well canstrucifcmpaaits(Le.WC.Carmt%State.Y ca eta) NIA ft.
ft. I in-
_
3.Weil Use(checkwefuse): /// R. I W.
Water Supply Welk FROM TO I
DIAL OF TtIICtIIC MATERIAL
l ticuliurnl —
Municipal/Public //A tL Im.
Geothermal(Liealing/CaotingStpply) lRtsidentisi Wau rSupply(single) ft. It; I In.
Indushia1lCommcrciat jIResidentral Water Supply(shared) 11£GRour
1LiiQdtioa moat TO INATERFAL I E5 WLAC D Ei TMETEIon&AMOU5ZT
Non:Water Supply Well: q ft- ac) it 51A o rilfed Pc r ,1 50113 b x
- EilMonitoring - _ __ DRccovcry IL Ih_. Chi ,t
Injection Welk P
Aquifer Rechatge OCuatmdrea2�Re<netiiatia3 19.SA
PiD1GRAVEL PACFC�oAI 1e
Aquifer5rotageandRecovery QlSalinityBarrier FROM TO i MATERIAL EMPLACEMENT METHOD
DBAquiferTest QStormwaterDtainage a A It: ft. 1 xperimentalTecimology jjSnbstdencConIIal ft. 1 ft. �-
Geothermal(Closed Loop) OlTracer 3so.DRILLING LOG(attsehaddiitional4 sif )
ID Geothermal(Heating�CooiingRearm) DOther(explain unde #21Remarss) o T° oxtm t rmrtuvice.matn�msl
1 ( op.ra; 1
4.Date Well(s)Completed:4-2N—� 1 WelllD I it; —d fe- R c k
5a.Well Location: ao n. S rowN S r cry so;1
&ro'/ I y r\ f4di'vves °\.$'': a3$' co uK
Facility/Owner ame Pacilky 1DP(if k) ft. IL
.3115 aVerI C0.rran3tkr\ l \61\1 f is , ,-'.
Physical Mddres.Coy,and 2+up (S X,{Q r \t N ,Q..t �,S 6 5 j 8, f. ' 'k.'�v,. L.i is ,.a.I, J
&rowlvi/le, 10\I coo aI.2,7v9c3 REPIAARKS 3 0 2024
County Parcel Identification No(PIN)
t o L; - ?r^2:, lin
5b.L titude and loongitude in degrees/minutia/seconds flnti/seconds or decimal degrees: 1...:: :1" l
(dwell field,onelatllong is sufficient) 32.Certification: ut"e v'./i-.
3�d �I / SO II N \%° 3 •' S5'' W i '/ , T i 1, .04— 4 -a-5' .! . .; .;, ,tvcutaonoaetoe / a�
Hare
6.1s(as.)the well(s . ermanent or DTemporary
Bystmtagekfsferia!!tidy eerafp tlwt de usll(s)uns irate)eatatructetl in atcatdance
7.110 this a rrpnir to an evisting Ivalk Dyes or.0910 tali LIANC.CILC.0100 ar ISA NCAC MC_OM Wall Construction Standards and that a
. Iftlits is a repairdilloutImawnwilcmutrrrilaainfamaitfaaendeeeplainthenateeofthe cola'ethic retan Marhem provfdeltothane]meter-
repair underb2l remarksseaianarea the baet.-ofth sforzc
23.Site diagram or additional wen detain
S.For CeoprobelDPT 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 only 1 GW-I is needed. Indicate TOTAL NUMBER of wells . construction details. Youmay also attach additional pages if.necessary,
drilled: 1— {� SUBlv(ITTALINSSRUCTIONS
9.Turd stall depth below landsnrfat e: a'si Qom) 24a,For All Wells: Submit this farm within 30 days of completion of well
For m,jltiple wells listalldepihs dhffared(example-eV eonsbtuctioaio the following'
10.Static water level below top of easing a o (ft.) Division of Water resources,Information Processing Unit,
Ifrvaterlevel is abate casing use=r`' 1617 Dad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Um) 24b.For intieruon WUelIn In addition to sending the form to the address in 24a
12.Well construction method: A I r P.ola r y above,also submit one copy of this folai within 30 days of completion of well
(t e.au constmcdonto the following:
auger,mazy,cable,dime:push,eta)
Division of Waterresodrees,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ('+ 1636 Ma Service Center,Raleigh,NC 27699-1636
ISa.Yield(gpm) I 5- Method oft `i Ati,3'Q 24e.For Water Svmpic&Intention Welllsa In addition to sending the form to
'J the addless(es) above, also!submit one copy of this faint within 30 days of
13b.Disinfection type: if T I-1 Amount: - I b. completion of wall conatroetiOn to the county health department of the county