GW1--04067_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1
L Wen Contractor Information: 1
5:Q--c-Tr Q..y T ,_ 1 Q1I\•S or• Id.WATERZONES I
We l Contractor Name FROM TO DWCRIrTI'ION
1 ,4 ! -1C� - PP'‘
4 t1. It:
NC Well Contractor Certification Moab= ISr OUTER CASING(for multi-cased wells)OR LINER�if 11eable)
Stephensonts Weil Drilling, (nc. �I TO e DIAA ' Tait .
Company Name C) tL I t 1 t I/ m. J 1)r. i P v L j
/ q L MANNER GR TUBING{6 +�closed-loan)
2.Well Construction Permit th /V ![ Z Y r!t\a 1©✓\ FROM TO _MAIMS I T _MATERIAL
List all applicable well construction perm' (e UIC.Cowaty.States wimtce.etc) IverA ft. ft. in.
ft3.Weil Use(check well use): IL in.
1'Water Supply Well: 1.s ERN TO ' DIAMETER SLOTSIZE TETIMIZES MATERIAL.
Agricultural DMuwcrpalll'ubhc 71t.
ft,Geothermal(Heating/CoolingEupply) DRtsidetttiat Water Supply(single} in.
dustrial/Commercial JResidential Water Supply(shared) 12.GROUT
ft
1nigation PRIMTO ' KAit M. _EMELACEMENTR'>EI IOD&A14IOLIM
Non-WaterSupplyWell: (1 ft. a� ft- or.,-fe, rQ;A( _4, sOlb 13A5Y
[]Monitoring Ditocovay R R C-h a-
j Injection Well: 1
pAgtrifer Recharge DGraunduraterRemediation 19.SAND/GRAVEL PACK_ a�
DAquifet'Storage and Recovery Salinity Barrier FRoai TO MATERIAL 1 EMPLACEMENT Ma nO1}
E31AquiferTest QStotmvaterDrainage /--// A - ft.
Technology DISubsidence Control "/ IL It. 1
Geothermal(Closed Loop) QTracer Zit.BRI...11 G LOG(attach aderi:ro sheets if n' ry)
Geothermal(Heating/Cooling Return) DOther(explain under#2l Renaults) fROM Tea ! MONt to atr- n �t
d ft. I R
T9� a i
4..Date Well(s)Completed: -A- 3.,P.."-1 Well I / EL 43 f rcowb so Ay -f 00
3a.Well Location: j4 3 � 465'f ?oe1�
1 I� I It fr.
� .(\fNl� n�12��r1rj� /
Facility/OcmerName Facility lDd(ifspplicble) D' R' •+.L.•41 . ',/ !
35 % -io►vNlI;ttr;+_Rc,. 0 Af orJ,N '_, .-A c i ft ft.
ft. J+�tig ?sit4
Physical Address.City,and Zip
C i cIr I"1�.1'1'1 71.REMARRS jp_s ,.: , 4-y'tors.v ii.l.
County Pauc,.l Identification No.(PIN)
3b.Latitude and longitude in degrees/a utes/seconds or derirnnl degrees:
(if well field,one Int/long is sufficient) 22.Certification:
%° 1�' -3-a" N —ACC i 5%t1 1
d'elbrsaay Si ell veil Conaaeuij-WIL'°*-d' Date6.Is(are)the well(s) Permanent or DTemno
By signing this form.1 hereby certify that the wells)wee(terse)constructed in accordance
7.Is this a repair to an eaiefgg well: Dyes or Zoo with IlANCAC 0?C_0100 or ISA NCAC MC MOO Well Construction Standards and that a
ffthis is a r pair,fill out blown weUawtrtruction information and explain the nannre ofthe copy of this retard has been provided to the well moor-
repair under 01 reworks sea-icn gran the flack of flitsform_
2.Site diagram or additional well det ils
You mayuse the back of this pageto provide additional well site details a wel
For Cetrprobet�pT or Closed-Loop Geothermal Wells having the sane
constructioon,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional pages ifnece,-szry.
drilled: 1- 4 G SUBMITTAL lNSTRa Cl ONS
9.Total well depth below land surface: ( v 5" ( ) 24o. For All Wells: Submit this form within 30 days of completion of wet
For multiple welts list all depths iferiferant(eraanple-301200'and 3®IOO) constitution to the following:
10.Static water level below top of casing: )Q (f.) Division of Water Resouretes,Information Processing Unit,
if enter level is above casing.use`-s-- 16I7 Mil Service Center,Raleigh,NC 27699-I617
11.Borehole diameter: G (r) 2d .For Injection Wells: In pfirlition to sending the form to the address u.24,
12.Well construction method: Al rabove,also submit one copy of this form within 30 days of completion of wel
P�Q�A f?I construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
?Avis ion 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 teals CTA�5t 24c For Water Supply&Injection Wells: In addition to sending the form tt
the 2ddaess(es) above, also cohmit one copy of this farm within 30 days n:
13b.Disinfection type: A T a Amount f'I completion of well construction to the county health department of the counts