HomeMy WebLinkAboutGW1--06632_Well Construction - GW1_20241108 0
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
-
..1L sec i 1 : <Kie.n�e.11-10r\• 14.WATER ZONES
l FROM TO DESCRIFfOPI
Well Contractor Name .aLvs it. a�' -
fL ,..� C 0 V'
����/ ft. f. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if table)
Stephenson's Well Drilling, Inc. FROM TO DIAMETER THICSItESS MATERIAL
Company Name C) ft. SD\ ft. ‘A fn. S `r*\a� VCR
c 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: IC) FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable Hell construedon permits(i.e.WC County.State.Variance.etc.) 11i m ft. in.
3.Well Use(check well use): 7 ft. ft.
I Water Supply Well: V.SCREEN
FRDM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural I icipal/Public f it f. ft.
Geothermal(Heating/CoolingSupply) 44 Residential Water Supply(single) i It, ft. in.
Industrial/Commercial Residential Water Supply(shared) iS.GROUT
Irrigation FROM TO MATERIAL. ElylP1.ACEMF.NTMETHOD&ABIOtltvT
Non-Water Supply Well: 0 a J �e40/-1�'� ?our t o Sc f l be CAJ'
Monitoring ORtxovcry rt. t>: J
Injection Well: • It Chi
Aquifer Recharge IJGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Bather Fna.s To I MATERIAL TEI6IPLACEhtEh"I METHOD
Aquifer Test }�1StormwaterDrainage ,/ [� fr
Experimental Technology DISubsuirnr'e Control 'V ft. i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
IGeothermal(Heating/CoolingRetntn) [�IOther(explain under;�I Remarks) FROM TO DFSCRI?tTo%(c lor.berdncss.seiUroetttype. iniize,ete.)
ft
y 1 0 ft. It� . � p p.ro f1/4_Date Well(s)Completed:1 I^ —a� Weil 1Dliz—J / D' I D. ' SO\Nc y I v'E.G C.1yl�n\i
5a.Well Location: • •J 'i ' ;.C."Q�11'N -Ci\l�N t I It
C7e .-Nt-ri.f 1 l t11Tlr1C. actrCI'1� Vkioil,,r Lc, a$ ft. a6 ?NocK
Facili /OwncrNatne Facility ib# ifa c...hlc ft. ft.
ry ry C Fpfi 1
''� ./ ft. ft. 4 . m..4
1 . :a.. '.r,, ,
I Z SeAc2PMM,(irlook.� 1 call �cc.n\Cl,r'O r•/h1,c., a-'I5 S
Physical Address.City.and Zip D' D' NOV ) s 70?A
Fro r K I in — 21.REMARKS -
County Parcel IdentifictionNo.(PIN) 1rr.`�,.,r.,.<.. i:. .•ii s, f
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
T. Atiii..„„ ii—i-
6.1s are thervelt s ermanetut or em o Sig ifs We,Contract° Date
( ) () P rary
�-^� By signt}rg this form.I hereby cert f5'that the well(s)was(were)conducted in accordance
7.Is this a repair to an existing welt: QYes or0No with 15AA'CAC 02C_0160 or 15ANCAC 12C D200 Well Construction Standards and that a
If this is a repair,pi out known well corurruction information d explain the nature of the Copy ofthis recant has been provided to the wall owner.
repair under d21 remarks section or on the hack ofthaform.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdifferenl(example-3Q2^000''annd 2 )1009 construction to the following:
casing:
10.Static water level below top of ,aV (&) Division of Water Resources,Information Processing Unit,
If water level is above easing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.BorehoIe diameter: ‘ (m) 24b.For Injection Wells:.In addition to sending the form to the address in 24a
�`l(. GL Q`�Cif\I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 ` 1 construction to the following,
(Ie.auger,mow,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(apm) as' Method of test: GAtA 5R' 24e.For Water Supply Sniection Wells: In addition to sending the form to
1,- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1'1 T FA Amount i 1 J, completion of well constriction to the county health department of the county