GW1--06623_Well Construction - GW1_20241108

WELL CO STRUCTION RECORD(GW 1) For Internal Llso Only. ' .
Lovell Contractor la6ramtton: 1
--- --e- - - 1 -, S+e P - eArl so n H.WATliR
PROM TO
Well tbnteutert!oae Pc .!c® � �°�o . 1. 6-PM'
a4a .
tti ft. 'i. ;
NC Well Contractor Ceedli aNua doer . - 15.OUTER CASING(for mall asedwells) r sk: Of )
Stephenson's Well Drilling, Inc. TO . t.r. I.K. wain
0 e. 10'-f �! %in' st c 1 v C.
compaeyNniae. , 16anOt$RCASINGOR Woodbine)*tiosed4a0al
2.Well Construction Permit* CS\\I 1 d.�Li I S' a4 kt
Litt ail applicable�carabucdcapermtls(i..MC Coumy:Slmtec Yarlam etc. A A ft ..
3.Well Use(chackman use): 1" ft. R. . k
Water Supply Welk r 1?.SCRUM M SMOTE_T �MA'TERIAL
it Apiculture! 014unitipsYPublic , IL tt. Ira.
■'Geothermal(Idm6ng/Cooling Supply) Ai•-- ,: Water Supply(single) N ft. h,L
lit Indus lallComenctelnl ■;Residential Water Supply(shaved) sac=otrr r I -
PROM TO $ASERW At 'IM*LMJTUOD&ASIOVNT
!Irrigation
Supply Wen: Q ft. ao it Ki n or;}e. Pods 10 5016 (Ay
I MonitoringElRcaovczy+ ft. tt:. _ C}�`l�'./'
_ -njecdon Wells •
a•quifer Recharge -{,Crt�+�....dwdatRemediat3� .l9 YLSLPACKBts��
' •offer Storage and Recovery I ty Barrier FRO TO MA _ �1R@I1lts trAlYIROD
�,AquffierTest ./ ter ft.
i•e_.. Technology Control I I' . at. ' • `
•:Geothermal(Closed Loop) 01'ftacer . . 20.BELLING LOG(snob adenoid sheets Wesossun1
MI Geothermal(!i Return) nOther(explain mtder#21 Remarks- Wita" T -Fop
MOSCPAMORkoliOnstfllvos.wende flte3
C� 1 !• i o f) rQ 1
4.Date Welt(s)Completed:ICI-a�=a`{wen1D0 I 30 ,�Le all s ,n�y cl
3a.Well Location: 30 '�.' C\\ lZ I7c®�r .si7., .`G�1
T c ,sv. NS e.\,o-c (7°` 'a`E s ; Ckci c. . y
Faa1RtylownerName [Di(ireppllt re) • ft .' • ft. _.
`'j- 1a�are ' e�.W �C. V OCe FOC2r-C al Sc4`1 - • .- ...� ,,,-•k_s; V ::,j
Physical Addrss.C1i.endrp D. I NOV o %�24
/n��M\,1take 1%d-3-13�0\1-1 2. .
Ceuuty Parcel>dt>l callo(Pfli) I I I i.J ...^ .` ' r'. A
: .-.,-, 7 l.
Sb.Latitude and longitude in degreedurhantestemonds or dedmal der .
Owen 6otd,ons itJlougissufficient) 22.Certification:
36® a' 30" N --VV 3% . —1ii w r G 1t -I—, I ,� {�` �-��
6.L(aee)the�!(a Permaaeut
or �: .•.. anal ' '8 Dale
- By despot Ibr� riot themot(ia�i amisbrrcledta
7.is this RXepai to an wee YYes orto with lid N ACO2C.OIOOarISANC4C WC.0Z00 NW(basou fro and that a
flake rirpslr.fIN our bayou toffaoasurmtlon6l(umadoetandeptain the aatreeYbe copygrthls mead har8aeieprosIfleslmthamaIowner.
Rpaair wrier iiTl rattans section oroalhabaelEofJ3rforuc 23.Mtn r or additional well detail=
S.For Geoprobe )PT or Closedd oop Geothermal Wells having the same You may use the back of this page to provide additional well she details or wall
won,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells constrwaiondstalb.Yatmgy also attach addidend pages lfnec away.
drilled; i SUBMITTAL ILIFTRUCI ONS
. 9.Told wdl depth below Nadsufacc cat+ (n) 24a.&NAM& Submit this foam within 30 days of completion of well
PrmulGplewzlla filial 1&v 4sfldracatfas la-36100'andWWI eonsinution to the thDowini
iQ Static water level below top of casing: J (n) Dfvieton of Water Besources,Tnmrmatlon Processing Unit;
Ifiompktuetis above dodo use+~[ 1617 Mail S rviee Caninr,Raleigh,NC27699-l617
11 Borehole diameter: v (in.) 2Ah For Selection Wellse�f In addition to sending the form to the address in 24a
12.WellCZ construction method: (�Al r 12•01-0.r V above,also submit one copy;of as Sum wig 30 days of completion of well
consnuction(l e:auger,sonny.cable.daootp sh,eta) to the fonowIng:
Division of Water Rest,Underground Iq[ection Control Program,.
FOR WATERSUPPLY WE IS ONLY: 1636 M USh rgia a Crater,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method oftesi C?O.0 gel 2Aa For Water finVnly&Jaieetlon Wen= .In addition to sending the faun to`
�.11P a )above. also one copy of this ihme within 30 days of
13b.Disinfection type: `'\T H Amos of well constnunton to the county health department of the county.
where constructed.
Fn„n Cow--1 NedhCesoliaa Decantnentoffkrthosnentel Onably-Division al Waur` Revised 2-22-2016