GW1--02640_Well Construction - GW1_20240501

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WELL CONSTRUCTION RECORD(GW-1.1 For Internal Use Only:
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1.Well Contractor Information: ' '
Ricky Corriher __--- -- ------ ---
Well Contractor Name
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2464-A a 3 8-S't' 3 d-•CS C . u
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NC Well Contractor Certification Number • -
Frank A.Comher&Sons Well Drilling,Inc. i>--1��111"o"'-4r' -11r:rt.•i.1`: -
ft. ft I in.. .
Company
�Name
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2ConstructionPermit#:12 Og If � g '7 2 --7r:a„.r.+ai,,..::, .: 1
List all applicable well canonicno'n permits(ce.IJIC.Comity,State.Variance,etc.) ENICIINIRICIMEGI SCR 21 we
3.Well Use(check well use)•• b ft- 3Qn r S-' _
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Water.Supply Wen: • i.+ '7 DIAMETER}ity:o,tizirllic e ,.r a♦
cultural •cipal/Public ft ft in.j
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft, ft. In.I I --
t Industrial/Commercial DResidential Water Supply(shared) r, - , -- .
Irrigation 111135111111111V.PA Pr°n IIIMIN117 ° w.i.01 u.ri.,i,r.(.)il;s,,•.+ir6
Non-Water Supply Well: ft. ft
• h Monitoring (Recovery • ft. ft. IMINIMIIIME
InjectionWell: -ft, ft,
Aquifer Recharge OGroundwater Remediation
Aquifer Storage andRecovery OSahntty Barrier .,��"CM111111111 . a ■a,:R.II•r °r:ri;,rar ,.,'a
l Aquifer Test CiStormwater Drainage ft. ft
)� Experimental Technology CISubsidence Control ft. ft.
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Geothermal(Closed Loop) [Tracer --
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
4.Date Well(s)Completed: 51 4 12-D%ell ID# MffalEgaIN ! y
5a�.JWell Location: Mil 1a R l y j /
�arkoia -I Arlon* d 112/e l fec ft f .. .
( MEI
CFacility/Owner Name ,yFaacciilityIINA(ifapplicablle) ft. R t _
`.( /a2 S),I r 4� Wit •'Ov< �P the R • Rt. ...r ey LI i
YY C
Physical
r 11111111111111.111MINMall
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......t %fr. Atidt2CItY,IxillP
Parcel Identification No.(PIN) .'
Count?' y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(if well Scam Iat/long is ) Q 22 C tion: i
35
6.1s(are)the well(s)t ermanent or [3Temporary Si of Well Contractor I Date
By signing this four,I hereby certify flat the xell(s)was(were)constructed in accordance
7.1s this a repair to an existing well: DYes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a ttym fill out knowsr well construction information and explain the nature of die ropy of this record has been provided to the well owner.
repair under#21 reunite section or on the back of this jorm. 23.Site diagram or additional well details:
8.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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. .
drilled: depth •
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9.Totat well tlt below outface: 0/ SUBMITTAL INSTRUCTIONS
(ft) 24a.For All Wells: Submit this;form within 30 days of completion of well
For multiple welts list all depths if rhfferent(crumple-3Q200'and 2®100) construction to the following.
10.Static water level below top of casing: 3 0 (ft.) Division of Water Resources,Information Processing Unit,
If‘wcter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: (0 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Drill above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following. j
(i.e.anger,rotary,cable,direct posh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Meal Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -AQ Method of test Air 24c.For Water Stun*&Injection 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: Stenlene Amount y vals completion of well construction to the county health department of the county
where constructed. I,
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-02 2016
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