GW1--04964_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. 1111171111
L Wen Contractor iaforma*io.
Ricky Cortiher —
FROM TO DESCINIPTION
Well CoamerorName 1f< (f'[ e ft. 13 5 01
2464-A ft. ft
NC wee Contractor Certification Nether — —
Frank A.Corriher&Sons Wei Driving, Inc. + TO biAMg,Et 11[AtBwAL
rt. s.
Cr ----_---
lftreall
6 3 -7 1 - 111 �'�.crt'I• I''ilM11111:.,::>:•1111M4'r41 T.%\111.1.1
2.Wei CamtraeKea Permit i
Lin all 4, -well cis use permit' (UIC Comfy.soak ra>i�C) MI a I it 6 It SUR-2i we
NM tiL
s.Well Use(eitedt..tR use):
Water r — s-I 1/' j
Water Sep@$Weld FROM To - DIAMETER scar sax imams& ianisiut-
tt. ft in-
t ...:.-...: ( Cooing Supply) ri '--.._..:. Water Supply(single) tL ft- ter,.
Claeridential Water Supply O — — — — --r.
PROM TO MATERIAL EMPLACEMENT BMIHOD a At.I00Nr
ft R
Non-Water Supply Wei — ---
■Monitoring DRecovery ft. ft
iaf seism Wei: ft. R-
Pecharge °Grow, water RoneeiiaDon —
• • .....;- Storage and Recovery C3Salmity Barrier FROM TO MAT19t1AL --- VeEPL.+fEtt TMETROO_ ._
DSt water ft
in i:..._.:.. Technology DSubsideace Control n- ft
t t ... (Closed Loop) MOM TO DM
__._.. - .• _- uaet a:n..e'++a.iSt..ic.
• ■ .._... (Hesffig Cooling Rearm) (=plain under#21 Remarks) m ,/
4,-ref
4.Date Weil(*)Comp+ Wen mn /Sr- ft- r� ft' 1")l u e ��n.
a3 tti j,c3 - `--j)l a- wh, . C -
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aa� roe(if w /
3� �/�'I,��.!! Gt G�c�( �.,-c �/)you 4 L ft. Mill l ::: I li
ft. R.
a'6, na.aty,meyn 0 — �� p
ak-e. /1 2 p
s )aeati5aaion rw cpnv)
County
Sb.Latitude and M gimde in degta/mIDute&/.eeands or decimal degrees:
(if well field,an tar/king is sufficient) 22
1.4
35. ''o 9 6 73 80 3 g53 7 w
,a,./: .,,.....Z F.c-C -0?
7
Signature of well Cooamxor Ruse
6 b(ass)the weinsItiermaneut or DTesuperary
By.siipting this forty.I iserebv cent:that the.aeli(s) .or(were)ca+`w.ned ix accv.daRce
7.la Ws a repair to an wasting well: Dyes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Coaunxaon Standards and that a
pits is a rep'.fill as known well construction information and acute,:the nature of the copy of tlua record hos been provided to the waU owner.
repair under l 21 remarks section or an the back of this forme 23.Site diagram or additional well details:
8.For GeeprebdD? or Closed-Loop Geothermal Wens baying the same You may use the bade of the p ige to provide additional well site derails or well
eon tiara,only 1 GW-1 is needed- Indicate TOTAL NUMBER of wells construction details You may also attar additional pales if Y.
drilled_ SUBMITTAL INSIRUCTIQNS
9.T. wen depth below had surface: ) `- (ft-) 24a.For An Wens: Submit dais form within 30 days of completion of well
For asuliplc wear Bee all depths if dry rat(example-3®200'and 2(4,1001 construction to the following
ie.Static water level base tap of casing: a
` O (ft.) Divlsiea at water Resources,hdormatias Process Unit,
Yisciser level is abuse casing.use"+" 1617 Mai;Service Center,Raleigh,NC 27699-I617
1L Boreisie diameter: Cm-) 24b.For lokecstoa Weis: to addition to sending the form to the address in 24e
Air Drift above,also construction to the o� 1 of this farm within 30 days of conviction of well
12.Weil_autr odious :
(Le-saga,nary,table direct push,etc.)
Division of Water Resources,Underground Injectisn Control Program,
FOR WAT R SUPPLY WELLS ONLY: 1636 Mall Service Ceara,]Raldgb,NC 27619-1636
13a Yield(wailMethod of t Air
24e.For Water Stymy&Iniection Wen= hi addition to crating the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Di.ntecaes tyPC Sierdene C AS compldiar of well constn�on to the county health department of the county
vy / where constructed_
form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016