GW1--02588_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW 4) For lnteinalUse Only.
L Well Contractor information: ,
7Ce f.cQ.1 .7-a + e r\so r1 ,
1a.WIAT1dRa�Oril� i
Well ContmctarNam FROM TO DESCRIPTION -
a a�. aa aaNqQ ft 31 crpm
NC Well Contractor Certification Nwnber ��� 3`�V M
IS.OUTER CASING(for mold-cased'naits)OR LEER[rf at e)
Stephenson's Well Drilling, Inc. . FROM TO DIAMETER ' Tffi MATERIAL
(No � Gl/t in. sp al P\ C. 1
Company Name -
�4 16. CASING OR3Zt�flrlfafta alcb l4ew)
2.Well Construction Permit it: FRO TO DIAMETER. MCf ESS MATERIAL
List all applicable null can structionpennhls(.e.WC.County.State.Variance.etc.) n�I ft. �
3.Well Use(check well use): t_/// ft. R. i in-
t It.SCREEN —
IWaterSuppiyWell:
FROM TO DIAMETER SLGTSIIZE THICKNESS MATERIAL
r
QMunicipalYPnblic IA t� it.Hcating/Caol ngSupply) 'ORcsidentalWaterSupply(singg.lc) r IL �,Industrial/Commercial QlResidtmfial Water Supply(shared) 18. En.
Irrigation FROM TO RItIATERIAL�� rEt?EIACEaEFlfit?EERODaAPrIOflFiT
Ilan-WaterSupplyWell: 0 it a) it. lefzton(l'2, ?oar I; Solt, hats
' Monitoring �Rccovcty It.
Injection Well: t CI'I(pp/Aquifer Recharge QiG oundvtaierRemeditdiott fr.Aquifer .Storage and Recovery �ISalinity Barrier 19.&AIaFi?dGR PACI>�ifattuticalt3c)'
FROM TO TO I MATERIAL F]IIFF.11CF14tmrriYlEEEiOD
D Aquifer Test DStormwaterDrainage N t R R
experimental Technology
Q1Suhsidance Cotrtrol '
Geothetmal(Clos�Iaap) �1Ttacer 2ILDR?.LLI;aiG LOG lettaeh additional shPetsMaeemsar5)
'Geothermal(Heating/CoolingReturn) flOther( plamundcr 1 Remarks) SROM Ta D7CRI'riolvt6az�.i�aass,soatecrrtty r Sara
p� n I ft Io()ro, I
4.Date Wel(s)Completed: 4--\-a \ Well 1. •'ft' .ac) ft' ' P\eick}� • Q.I o.j .
5a.Well Location: ..}. 2-Q it' ` tt I ' lac o W -' c c w -PC,
� ? Iorne,s - cKc),S kQri=o r\ stofiz.r ag, , : 3G 5'ft* Roc a- ' 1
Facility/OvmarNamb Facility ID:4(ifacpflcabte) O. f
Ira S r,�o\NI e_ hr. WAS Fora t N,�.t ai S,6i ft. it.Physical Adt CiJtty,and Zip R. ft. l''%-.-�i.,r i yV ;^
Csro,twdie i6.a,,,kOO tE00 c a ,l 2fl.REMARKs APR 2 G 2024
County Parcel IdentificationNo.(PIN)
5b.Latitude and iongtude is degreeslnaituttsslseeomds or decimal degrees: r-' ., •,_, L. , ..
(ifwell field,one latRong is sufficient) j r 22,C � on: { l.r:fu Cu"3 ;
`,\\� �/ 3 /f N 5D a 3 / -- 0 /f W \,I I Lk- - 1
c(
Sil41, •..:.r..WellContrac r Dare
6.ls(arc)the well(s)- jI:eranent or OTeratporatra+ .
By signing this form I hereby cart&that the trail(s)war('care)constructed in accordance
7.is this a repair to an miming well: Dias OTJZINO with 15ANCAC OZC.0IOO ar 15A JUCAC 02C.02118 Well Construction Simular&anti that a
. If this isarepair fill out hnoaai well construction information and explain the nature oft he cola'oftl&record hasbren prolkled to&mall owner-
repair under m21 remarlssection area thebackofthisfarm.
23.Site diagram or additional well degas:
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,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells
construction details_ Youtnay also attach additional pages ifnecessary.
drilled: . . SUBMITTAL INSTRUCTIONS
9,Tonal well depth below land surface: ( ) 24a, For MI ells: Submit this form within 30 days of completion of well
For multiple wells!Este l depths rig:erent(example-3(2O0'and VIM) construction to the followinx
10.Static water level below tap of easing: 30 (ft:) Division of Watery Resources,Information ProrPRe a Unit,
Ifwater lave ll is above casing use-t-- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C (Ia) f 24h.For Infection Wells In addition to sending the form to the address in 24a
i2.Well construction method: A l r �(i I.A f y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(In auger,rotary,cable,dixeet push,etc.)
Division of Water Resonrces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mal Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method off test: Go,(A De, 24c.For Water Simply&Tuieation Wells: -In addition to sending the form to
/� I the addo s(es) above, also submit one copy of this formwithin 30 days of
17
13b.Disinfection type: T ii Amami completion of well construction to the county health department of the county