GW1--02937_Well Construction - GW1_20240513

H
•
•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
"Till .
1.Well Contractor Information: P
Ricky Comher '
Well Contactor Name � tii— `DF SC BIP'['[ON _— --- --- .
tPngAIIIIFsarAMIIIIIIIIIIIIIIII
2464—A ft'
INIMIIMINIMIIIIIIM
NC Well Contactor Certification Number •
Frank A.Comher&Sons Well Drilling, Inc. i-00J,,,fv,iiiiiiiii c......JAiiiiiita --
ft. ft
Company Name in, � . .
2.Well Construction PerIDrt#: ' � t'//,' .5 7 I (/�r b/ q E il'1+i,1-M r:; .. ,4..01.& _-- _
. List all applicable well contra on.. ,(i.e.UIC,County,State.!'triune,ete) Mill 0 0 ft• 6118 ,in' SDR 21 rue -
3.Well Use(check well aria): MOM'�� `
Water Supply Wen:
Agricultural ' DM•.-cipal/Public ft, ft. m: • .2+1J .
' Geothermal(Heating/Cooling Supply) 14.' .idential Water Supply(single) ft. ft in
Ind ustrial/Commercial . DResidential Water Supply(shared) - -- _• • .-
Irrigation - '�ir r :s • HIadu:s;Trpi,trlaci:t:D1Q•`V;,Olifai/
Non-Water Supply Well: ft. ft-
Monitoring • , f Recovery .ft . ft...
- injection Well: -
Aquifer Recharge OGroundwaterRemediation
er Storage i
Aquifer torag and Recovery Salinity Bonier to a„i:w rw ,Dow i.;,r t.,°,1♦
' Aquifer Test , QStormwater Drainage ft ft
• . Experi l Technology . [3Subsidence Control ft. ft. -
Geothermal(Closed loop) CiTracer
Geothermal(Heating/Cooling Return) Daher(explain under#21 Remarks) limit,U ft. 'ye
w-9ffgaimErimi
zi
4.Date Well(s)Completed:-.) O" Well lD# MU, ) ft '
5a.Well Location: IMIZMr��.�.`
ke,y t 2OSse, —� - ���.e f ., ;=,; ,./. c.:i
Facility/Owns r Facility (if app 0/ it . ft
G. lh�' IIIIIIIIMMIIMIIIIINIMIM
• ) r / Y'./ ft tt Numumt 1
s J 2, i o fer7 J'�1 k bdl/'
Physical Address,City,and /+ � ft ft t r< °i
Rai 4 .42 G?
County Parcel Identification No.(PIN) ' '
I 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell f/i�eld, latllong is�ufficient) p� 22.Certifi Son: . .
350-6& 1; & N 8C),(7313(2O g w i U 3-„av 2
6.b(are)the wel1(s ermanent or a Signature of CerBfibd Well CBntractor' Date
�I > y
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stmrda ds and that
If this is a repair fii out knot will construction information and explain the nature of the ropy of this record has been provided to the well meiter. -
repair under#11 remarks section or on the back ojddsform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or hosed-Loop Geothermal Wells having the same
construction,only I GW-1!is needed. Indicate TOTAL NUMBER of wells details. You may also attach additional pages if necessary.
I
dulled SUBMITTAL INSTRUCTIONS
9.Total well depth belawl land surface: �3 . (ft.) 24a..For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(fdrfferent(maniple-3®200'and 2Q100')
construction to the following:. 1
10.Static water level beddw top of casing: • % O • (ft.) Division of Water Resources,Information Processing Unit,
Ifwater keel is above casing use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: I 1
(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction me ho 1: Air Drill • above,also submit one copy of this form within 30 days of completion of well
(ie.anger,rotary,cable,direatp1. a,etc.) construction to the following: I
• Division of Water Resources;Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test:Air • 24c.For Water Simply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterie:ne Amount F' C / > completion of well construction Ito the county health department of the county
where constructed.
•
Form GW-1 North Carolina Dent of Environmental Quality-Division of Water Resources Revised 2 22 20I6