GW1--03328_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor Information:
,--Se__Air e.� T r `S}�I 1 6 ,i1-1 0.n 14.WATERZONES
ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-rased wells)OR LINER(If e)
Stephenson's Well Drilling, Inc. PROM TO J DIA1p THICKNESS MATERIAL
Company Name Q) ft i c!'1 r, iL C .,1 ' in. - n 1RN ' C V Q, 1
t ( a'Nr 1 1 INNER CASING OR TUBING t hernial erased-Ioop)
2.Well Construction Permit#: �� TO DIAMETER MATERIAL
List all applicable well construction permits(i.e.U!C County.Sate Yarlance.etc.) A./A ft ft. ln.
3.Well Use(check well use): n' n
`Water Supply Well: t7.SCREEtd
FRObi TO DiAbiE.TF1t SLOTSrlE THICKNESS MATEBIAI,
Agricultural DMunicipaUPublic N/A[L R. tn
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) at. f:. In.
industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri cation FROM I TO I MATERIAL METHOD&AMOUNT
Non-Water Supply Well: ft .D.() ft. •,,Lf 9rLte 717soJ h(,,j_,
Monitoring DRCCovery ft. ft. C.i\,r,r
Well:
Injection eft. ft.
Aquifer Recharge QiGrounderraterRemediation
19.SAND/GRAVEL PACK(if appfcable)
Aquifer Storage and Recovery Groundwater
Barber FRO TO MATERIAL EMPLACEMENT METROD
Aquifer Test Q1Stotmwater Drainage n/ EL
Experimental Technology Subsidence Control $ ft.Geothermal(Closed Loop) DTtacerdte20.DRILLING LOG(Moth additional sheets if necessary)
Geothermal(Heating/Cooling Return) O (explain under#2l Remarks) FROM To DESCRIPTION War,trardamt.sotitrocktype.grain sin dr.)
Cl ft. rft. i./ c ',
4.Date Well(s)Completed: _ac,- t1\Weell ID# —
/ ft. as- ft-" /`\,,i, -f c A,,i1Ni C/'`�l
5a.Well Location: ,J�� 1 t0 r .1 0uk^k1'�QJ�✓ 1r\c-� as M' `7 ft. S�_C\ !
L_c;:v ‘ s ___ to, Ac.f t',s Lot 3 3 ft a`X SJ 11; fi 0 c.I{
Facility/ erNamc Facility Me(ifappReablc) R. R
j Lzl ,I�Ar� Lh, L-OUIJtUr ITC. a1 S-1,\ ft. ft. ,
Physical Address,Ctty,and Zip ft. ft. sik..014 v 2024
2L REMARKS
Fr.a 1'^ �Ir
County Parcel Identification No.(PIN) .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.`one let/long is sufficient) C( 22.Certification:
,3\' wit -> A"
. N -� "%° 1 S- r �11 W
1 , Xtr. S-as . aLi
ftstdaid
6.is(are)the wells) ermsfent or Temporary Si Wc11 C0°trac Date
By signing this form.I hereby err that the uietl(s)war(rene)constructed in accordance
7.Is this a repair to an existing well: ( Yes or. No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construe ion Standards and that a
If this is a repair,fill out known well construction information curd esplani the nature of the copy of this word has been pranced to the well owner.
repair under#21 remarks section or on the bark of thtsform
33.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-1 is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional pages if neerccary.
drilled: . ] �( SUBMITTAL INSTRUCTIO)
9.Total well depth below land satiate: C v (T) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdgerent(ewmple-3Qa 200'and 2 ,100) construction to the following:
10.Static water level below top of casing: 3 v (ft.) Division of Water Resources,Information Processing Unit,
If meter level is above casing,use'•+- 16I7 Mail Service Center,Raleigh,NC 27699-161
II.Borehole diameter: -i OW 24b.For Iniection 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: I r 1"�Ci 0.j�l construction to the following
(Le.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 test G t'NA 3 Q.. 24c.For Water Supply&Injection Wells: In addition to sending the form to
14-
� __ f . '�� the address(es) above, also submit one coP3 of this form within 30 days of
l 13b.Disinfection type: + I I-( Amount . completion of well construction to the county health department of the county