GW1--03094_Well Construction - GW1_20240522

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WELL CONSTRUCTION RECORD(GW--1) For Internal Use Only.
1.Well Contractor Information:
--Z-Q..*{-Q.I 1 &k-erke-11J D r\ FROM ERZOIVES
FROM TO DESCRIPTION
Well Contractor Namea 1 O I c ( ' S� m_
aya� p\ 1
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING(for multi-cased wells)OR LINER(if lIcable)
Stephenson's Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
Q ft. ` '13 ftt. it>.�.1/' pr. al 1'V C
Company Nnme �\ � 16.INNER CASING OR TUBING(geothermal ciosed-toap)
Ll
2.Well Construction Permit#: \ Q p-\3) FROM To DIAMETER THICKNESS MATERIAL
List all applicable null construction permits(i.e.UIC.County.State.Variance.etc.) AV ft. flu m.
3.Well Use(check well use): ft. t. in.
Water Supply Well: ( FROM TO
N/A ft. DIAMETER SLOTSIZE IffiCt�PSS MATERIALMATERIALAgricultural DMunicipal/Public ft. in.
Geothermal(Heating/Cooling Supply) DRtsidcntial Water Supply(single) in.
Industrial/Commercial �Roidential Water Supply(shared) 1&GROUT
[-I Irrigation FROM TO B?MATERIAL , llsa.c MENrMEIHDD&AMOUNT,
Non-Water Supply Well: V ftao -t,f,i-a 11tQ roar a Sct16 hni-
jkMonitoring [Recovery ft. it cue J y
injection Well: ft. ft.
3Aquifer Recharge DGranndwater Remediatioa 19.SAND/GttAYfiL PA (If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMFLACEME?FM rROD
BAquifer Test QStormwater Drainage Iw/ A ft. ft.
Experimental Technology (Subsidence Control V ft. ft.
(jGeothermal(Closed Loop) Tracer 20.DRI[LUM LOG(attack additional sheets if necessary)
Geothermal(Beating/CoolingReturn) Other(explain under#21 Remarks) FROM I To I DESCRIPTION sitar,eardaas sat!lroekryas�s;a ail
0 ft. Ift. 1 of,Tv, I
4.Date Well(s)Completed: S' I -aLk Well IB# I ft. q9 �t'0 ft. Red c.11›,y
Q
Se.Well Location: I ft- tl s r0 W r SON"ck.y G►1
•
�SC,r,\Z,i- Los ter, \rt rip"„\J C“. ft: -a.5ft. Paock
FacilitvlOwncrNamc ' Facility ID (if applicable) it ft.
-s°'I P h;t. w h' t f „+ li s-_ e ft. ft.
Physical Address.City,and Zip ft. ft.
CT r c rr
21.REMARKS -...+.• x...r (,r�-._1 ,
\r I I t' \% --1C�7,`k 1e\`t 1 PA
County Parcel Identification No.(PIN) j G vG T
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one Iat/ong is sufficient) 22.Certification: r.':; .1 .j?I
6_Is(are)the wells) (Permanent or DTemporar!r sib.•., ell Contra Dam��TT ONo
By signing this form.I hereby ce=OPP that the Dell (irz
s)uns re)constructed in accordance
7.1s this a repair to an existing well: DYes or utth ISA NCAC OW.0100 or 1ST!NCRC 02C.0200 Well Construction Standards and that a
(phis is a repair,fill out known well construction informationxplain the nature of the copy ofthis word has been pmvided to thecae!!°met.
repair under fl21 remarks section or an the back of thirform.
23.Site diagram or additional well detarlr_
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details- You may also attach additional pages if necessary.
drilled: a SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �ca.5- (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((deerent(example-3(200'and 2Q1001 construction to the following.:
10.Static water level below top of casing: v (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+` 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cm•) 2413.For Injection Wells: In addition to sending the form to the address in 24a
} above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ail- �v 1 C f y construction to the 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) I • - Method of test r to J�'. 24c.For Water Simply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
/
13b.Disinfection type: 1 I ti Amount: ._ I hi completion of well construction to the county health department of the county