GW1--02591_Well Construction - GW1_20240426

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WELL CONSTRUCTION RECORD(GW 4) For Internal Use Only:
i.WA/ell�Contractor Information: 1
e,l'Tr rQ. t S Q ekeiNf r 14.WATERZONE
Well ConbactorN e 1 FROM ,TO DESCRIPTION
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NC Well Contractor Certification Number �3 S a. 2,3 S a G 1 M
IS OUTER CASING(for multi-cased wells)OR LINER Cif an lieabie)
Stephenson's Well Drilling, Inc. FROM ..TO. DIAMETER ISICENESS RRATERIAL
m 6 fit.
Company Marge V iL 5 l/lt in. S O r'N al V
T. 3.� l 16.1Ni Ss G CA OR TR RING.(geothermnl cio .Ieu )
2.Well Construction Perinit#: FR TO DIAMETER TRIMNESS t>saaraint.
List all applicable null construction permits(Le.WC,Courtly:State,Variance etc) AIL It in.
3.Well Use(cheekwef use): ft. fa 2°' _
Water Supply Well: 1?_SCREEN
FROM TO DIAMETER SLOTS= TRIMNESS MAMMAL
Agricultural oMunicipaUQublic 1tl AIL fr. . in.
Geothermal(Hcating/CaolingSupply) Residential Water Supply(single) rt. it. ' in.
Industrial/Commercial oResideatial Water Supply(strafed) in.GROITr -
irrigation FROM ' TO MATE.ITAL ' EilIbACEI 2i TWE OD&fARMENP
Non-Water Supply Wells 0 ft. 00 k B e,n 1 o Ali-e• Po uu I I s' I
d l D 1JA c
Monitoring jRccovery ft. ft- r' LNif s J
Injection Well:
Aquifer Recharge GmtmdwaterRemediation
I9.SAND/GRASP.PACIC(IFadplicable)
Aquifer Storage and Recovery 1:3O1Salinity Border FTaoi TO MATERIAL EMPLACEMENT METHOD
DAqutferTest �IStcrmwaterDrainage ft.
ExperimentalTeclmology OSnbsidenceControl 1ft f�It ft. -
9Geothermal(Closed Loop) DTlacer 20.DRILI.I GLOG(attnsh additional ifur sary)
Geothermal(Heating/CoolingRealm) fl0ther(explainunder#21Remarks) �O� Tra Dssrnal>xriOrrrsarant R cclttbtx&syFc. ses:metas
�-{. z( 0 ft t 1-0eJOU
4.Date Well(s)Completed: l t I Ti-a `bye11 JD# 1 ft. 3 Q .it. ! c. 0\V
Se.Well Location: 30 ft. 1 I S f� h1!\
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FaeilitylOwnerNamo Facility lDP.(ifappliceblc) ft. Ct '
1$00 Pesv-h Orci)Arel N(dt LUU1if1j(Ars -1S- "\ ft f7.:..7: ; ° _
ft.
Physical Address,City,and Zip
Fr�>`rc I;� 21.rz�n arcs; 1L `u
PR 2 C z4
County Pared ldentificadenNo.(PIN)
Sb.Latitude and longitude in degreeshminutesfseconds or decimal degrees: U'.`,-::,;A
(ifwell field,one latnong is sufficient) 22.Certification:
arse fsewell s errrianeiEt or Tam orara Si.. .. • »: cd WeliCanti2c Date
6-3s( ) (1P
By sigafag this farm.I hereby certrf1.°that the uell(s)inns(Iiwe)constructed in accordance
7.is this a Pepeir to en existing yell: QYes Or T21114To rids ISANCAC 02C.010D or ISA MAC 02C.0209 Well Construction Standards and that a
Ifthrsisartpairfill°uthrtom well canrauctianinformationand=plain the nature ofthe MB'ofihis record hes hew provided to Mandl mew-
repair under RZ1 retnarlasection Oren the bark ofdds-farac
23.Site diagram or additional well details:
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-I is needed. IndicateTOTALNUMBER ofwells constiuctiondetalls. You mnyalso attach additional pages ifneeessaty,
drilled: 1- SIJBIIII1TTAL INSTRUCTIONS
9.For,nTotal litpte l depth tselovaltamdsilrkace+ �� (IQ .For All Wells: Submit this form within 30 clays of completion of well
For multiple wells list all depths ifet f ere.nt(example-3@M°and 2©18D3 eonstrucdon to the followinz,
10_Static water level below top of casing: 3 0 (ft) - Division of Water Resources,Information Processing unit,
!fewer/evens above casing use-r-`[ 1617 Mail Service Center,Raleigh,NC27699-1617
11.Borehole diameter: (iin°) 24ta.For lineation Wells: In addition to sending the form to the address in 24a
A above,also submit one copy:of this foam within 30 days of completion of well
12.Well construction ffiethad: t r0 I t A r y consbrucuon to the fhllowinx
(Le,auger,rotary,cable.,direct pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ( 1636 Mail Service Center,Ralelgb,NC 27699-1636
13a.Yield(gpm) 5 Q Method of testi <j AU,ye..i 24e.For Water Supolv ps Injection Wells: In addition to sending the form to
1 , T Il-1 the address(es) above, also submit one copy of this form wit 30 days of
13b.Disinfection type: `-} Amonnti � lb r completion of well construction to the county health department of the county