GW1--03648_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD 1GW--1) For Internal Use Only:
L.Well Contractor Information:
-Se.-kkc T , Rkefikes r%.rn 1, PROM ZONESO DESCRIPTION
Well Contactor Nand
a`1 130 11 rk Cis M
NC Well Contractor Certification Number 1 -1 ft- 1 V ft- �,
15.OUTER CASING(for multi-cased ward OR LINER(it e)
Stephenson's Weil Drilling, Inc. FROM 1 TO ' Dwain moons MArE Al.
Company Name Q ft 1 l'i�1" I v ' S t)N_aL 1_ V c.,'
I� 16.INNER CASING OR TUBING( closeddoo _
2.Well Construction Permit#: 1 Q I 0 FROpI TO DIAMETER. TIRCECNESS MATERIAL
List all applicable urll construction permits(i.e(ftC.County,State,Variance.etc.) fir'/4, ft. ft in.
_
3.Well Use(check well use): 1 n' n 'n.
Water Supply Well: 11.SCREEN
FR TO DIAMETER SLOT SIZE THICKNESS M.TEBIAL
Agricultural �1vinnicipal/Public �v R. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) /', t. In,
Industrial/Commercial Residential Water Supply{shared} t.
18.GROUT
Irrigation PROM TO -MATE RiAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Cj it . \J ft B l\OPa 'ri- [1 r 1 3 s v l k U(; �1J
Monitoring DRecovcry ft. ft. C r
Injection Well: ft. ft.
Recharge DGrotsndwater Resne•diatioa
19.SAND/GRAVEL PACK(lf eprlicnble)
Aquifer Storage and Recovery Salinity Barrier FROM TO atAT RIAL EMPLACEMENT METHOD
BAquifer Test QQStormwater Drainage n/ ft•
Experimental Technology OSubsidence Control ft. ft.
9Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach addidrund sheets if accessary)
Geothermal(Heating/Cooling �Other(explainunda"21 Remarks) FROM TO DESCRIPTION(agar.hankies.son/rock ty-pe.� dr.)
—
ft. I 0 i.C`1,
4.Date Well(s) G.Completed: 3—all Well ID# / (t. .c ft. ��, J Cn BAN c
5a.Well Location: / av ft. t �� ft. ILL
V b 11.E } Id Itr1L/ ► Vasil^ tOrN i\C«.-J. li± I Ii: jg5 ft. PN;.tC.K
Facility/Owner Namc Fea lty IDC(ifapplrable) ft. rt. . !1 f U
S .
J
I.30 L&t-vireLhl Lo(n burs �.� Q� r`4� ft ft. F++�+ �t p �p
Physical Address.Gry,and Zip ft. ft. 1 V t y 1 p C U 24
bra„ /, 21.REMARKSvt4.464--il t I"
County Parcel Identification No.(PIN)
D'h(11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(IF well field,one iat/iong is su&cime) 22. :
/
3s" c/ a s N --1 ° IC 3\/' W %l�_m `'� G- 3-are the welI s Pe *sranenE or Temnnrart SIJI ?T'c d Well Contraco Date
6.Is( ) (s Q
6),signing this faun.I hereby certg5'that the nrll(s)tiny(uere)constructed in accordance
7.Is this a repair to an existing well: DYes or spiNo with 1SA NCAC OW.0100 or 1SA 1/01C 02C.OZOO Well Construction Standards and that a
If this La a repair,fill out hnomn well construction information and explain the nature of the cope of this record has been provided to(helve!!owner.
repair under#21 remarks section or on the back of this-farm.
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 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional pages if necessary.
drilled: SUBMITTAL 1NSTRUCTxo: L
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple iculk list oil depths ifdifjerent(example-3 a@200'and 2eloo') construction to the following:
11
10.Static water level below top of casing: � �r (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing,use"+— 1617 Mail Service Center,Raleigh,NC 27699-1617
;1.Borehole diameter:
M) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air i
12.Well construction method: / ` r R G4-0‘r, y above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
1 Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ('� 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 15- Method of test V A tA3Qi 24c.For Water Supply&Infection 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: / T/l l Amount: .1. 16, completion of well cousbuctim to the county health department of the county