GW1--03089_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW I) For Internal Use Only:
1.Well Contractor Information: _
�e'c"ir Q v/ %4,92.L,eir\ o r• 14.WATERZONES
Well Connector Name 1 1 FROM TO DE�CFtrPfION
Aa-30 ft. 230 ft. f^n
a., R.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER Of ,u. - .e)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER TBIctCVESS MATFRtA
Company Name �j ' ' ,Iil;t in.--Q(t A I T,Th"I �
L.L. r` .-, r� 16.INNER CASING OR TUBING( ff thermal closed.lo
2.Well Construction Permit#: v J FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction permits(i.e.UIC.County.State Variance etc) iV/A in.
3.Well Use(check well use): ! ft ft. in.
Water Supply Well: 11.SCREEN
FRO TO DIAMETER SLOT SITE TmCIQ�£SS r.s*r nr*.
Agricultural DMtmiciptrl/Public J✓ !j ft.
E ft.
Geothermal(Heating/Cooling Supply) .,Residential Water Supply(single) ft ft, in
Industrial/CommercialResidential Water Supply(shared) i&GRODT
rihuigation FROM TO1 MATERIAI EUPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � ft' rZti ReAo^1t'e Pour SQI, b0.51
Monitoring DRccovcry 0. It. C ki,S
Injection Well:
0. ft.Aquifer Recharge DGtoundwater Remediation -
19.SAND/GRAVEL PACK(if agelr bo-)
Aquifer Storage and Recovery DlSalinity Barrier FROA TO MATte_RIAL II12PrACEMETTMLTTROD
BAquifer Test DStormwater Drainage Ai/A ft- ft.
Experimental Technology DiSubsidence Control ft ft.
9Geothermal(Closed Loop) Tracer 20 DRILLIP(G LOG{Mach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain undo#21 Remarks) FROM TO D&scltzpnox(oedar,hardness.soithoett type main s a eta)
4.Date Well(s)Completed: CI I'(-a-k Well IDl j 0. I ft. Rehi s k,,sb,1_ \l
5a.Well Location: 1 ft. 1 c" >L roWa SOS .s'o 1
c,r..yt tforw..-r/ fr►rjYi f\ Acrts Lot Lt -1 s' f DA S ' POtrK
Facility/i Name Facility ine Cif applirable) R.
`}, L+`i,t tire !=-ram. LOtn(f hkr3 rNkC • ��. -C`( `1
ft ft ti..:i v
Physical Address,City,and Zip 0. 0" 2 L 2n74
Fro\/1 K/1n 21.REMARKS
County P.uc,.1 Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3bC / -36" N 7c6° Imo' Li S„ W ak T t .�J s S/4-ai
6.Is(are)the wells) Permanent or DTemporary Si_ Well Coatraotn Date
�� By signing this form.I hereby cef, 'that the aaIl(s)wan(Isere)constructed In accordance
7.1s this a repair to an existing well: Dyes or SZrNo with ISA NCAC 02C.0100 ar IS IVCiC 02C.0200 Well Construction Standards and that a
ffrltis is a repair,fill out knann well carrrtruction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form_
23.Site diagram or additional well details:
o.For Geaprobe!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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details You may also attach additional pages if neSsaty.
drilled: .1. SUBMITTAL INSTRUC11O iS
9.Total well depth below land surface: O (f) 24a. For MI Wells: Submit this form within 30 days of completion of wel l
For nud[iple wells list all depths ifdlferent(e omple-3Q200'ond 2@100') construction to the following
i0.Static water level below top of casing: _3 Q (It) Division of Water Resources,Information Processing Unit,
If water level is above caring.use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
il.Borehole diameter. \v (m.) 24b.For Injection Wells: Its audition to sending the form to the address in 24a
np above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: .t [1� A r construction to die following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tests Cl a<n_) 24c.For Water Supply&Injection Wells: In addition to sending the form to
I
/ I the addresses) above, also submit one coP1 of this form within 30 days of
13b.Disinfection type: [i T/1y� Amount; I h► completion of well cons(tuctio:a to the county health department of the county