GW1--02621_Well Construction - GW1_20240501

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Inforngtion: • i'
, 11117
Ricky Corriher
Well 2 ContractorN�e ' rft. ft.
ft.
NC Well Cofactor Contification Number •
Frank A.Corriher&Sons Well Dulling, Inc. rt iit if :; +4 r r,r'.;,1;::-1. kiln,A;,-'-.
t t ��y� Q '
V
2.Well Construction Perini!#: �JV 63 y
,,,,..�i i i a:Yr 3.iiiiir.i:r..;lxviii iii.. .tIA(. __.-_-
permits County.State.Variance.etc.) Ural 1 ft 61/8
.SDRY:t me
• 3.Weil Use(check well me):
F
Water Well: � . ���
■ t lifat•i•
��R+n t tri,,i-,r+it[. .• i r.+ 11
rtrrini
tapa1/Pttbha tt ft. in'/
—
■Gil(HeatinE/Cooling SuPph9 t: - —.,.: Water SupPlY(single) ft. ft. 1 III �id ai Water Supply(mod) _ _ .. -- M.
- ---
Non-Water Welk on mon E'mnim ttr,,:iri i
ft. ft.
II Monitoring f Rccovay
Infection Weil. :•
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ft. ft. —
ft. ft.
DCmundwat r Re mediation
■ -.,6 and Recovery ['Salinity Barrier - '- - - - —
II Aquifer Test DStormwaterDrainage ft ft
. , ■Experimental Tecbnolog3' ['Subsidence Control ft ft -
_ _
■ (H gtCoolmg Return) Dottier' (explain under#21 Retnadcs) 11 "/"�© >.-"'L•,,„r- . , _z, .•T_'
4 Date Welke)Conte: T�r�`L. Well B7# It ��M�
Se.Well Location: ��y.dam f o E�" C �MiM
Class 3i �7 W! € �,
ft.17/7. 61a/2 Gi/ Iv/
Pb�City,a� -.”:.:-_-_::,.-.--..-.:::::::7_::. -ft. MAY u i [ — —
CiA ica77
Cry Parcel a No.(FIN) ca vi i l �,irr �`ri `: um
+
S.I.atitsde and loug�dein degree/mmates/seconds or decimal degrees: I
Gbd ".3:.y.:;
6.Ware)deeweli(s eranent or Qremporary s'., 20...tii . eir_.,z_ i
„•, ofC d Wen Date
BY.signing is form.I hereby'-en&6 that
this the dI(s)MY(u constructed in accordance
7.Is this a repair to an existing well: DYes or sick ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Contraction gtmedmdis and that a ---
Ifrhis is a repair.fig ow ban*well ca stru Lion 01*stacon mid captain the nature of the opY ofyas record has been provided to the sell( aer-
repar eider#2I rernaris sealcet or on the back ofthis form.
23.Site diagram or additional well detail:
8.For Geopt»be/DPT or 1osed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
drilledconstruction,only I GW-llis needed. Indicate xerAL.NUMBER of wells won details. Yon may also attach additional pages if ne ly,
belowl SUBMITTAL)NSPRUCTION;
9.Total will depth lattd surface:
Form,daple+a is li tail depths¢ treat(e ample-�00•m�®2 (ft-) cons Far MI wells: -Submit this form within 30 days of completion of well
O construction to the following:, '
10.Static water level1,
below top of casing: (ft.) Ilivislon ofwater reader level it above casing.hoe"+^" Re�uTcea,Information Processing Unit, •
1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: en.) 24b.For Infection Wells In addition to sending the form to the address in 24a '
12.Well n Air Drill • above,also submit one copy of this form within 30 days of
(is" mousy, , ) construction to the following O0 of well
FOR WATER SUPPLY WELLS ONLY: Divmerion of wafer Resources,' Underground Injection Control Program,
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1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(Rpm) i Method of bask Air 24c.For Water Strove 8c lineation Wefts In addition to sending the form to
136.D fiou type: ! Amount �i p.5 the address(es) above, also submit one copy of this form within 30 days of
V to the county health cheat of the county
where constructed.
Form GW-I •
North Carolina Department ofEnvirot®mml Quality Division of Water Resources Revised 2-22 7016 .
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