GW1--05100_Well Construction - GW1_20240827

I
Mr
WELL CONSTRUCTION RECORD(GW-1) 1 For Internal Use duty: i
1.Weg Contractor Inform:So
Ricky CO(T7 To
moat •
Well Contractor time d 'ct 3 t I .1./
2464-A a2 n. 5-ft. ( C-o-l'
ldc Wen Cyr Ca>i bon dumber - —
Frank A.Corriher&Sons Well Drilling, Inc. PROM TO MAMMA ,saw stAreinaL- ---
s. ft.
Creamy
Name Qr/
2.Wel Caest ect ere Permit it:
smart TO txiasan�t t>n[7�S NATAL
Las all applicable well ce. P (Le WC.Cathay.Sam Variance.ac.) 7r ) / © R I
3.Wen Use(Check well oCx ft ft- s 6c' is stet .� /
Water Supply WeR: weoet --TO. _ _-t sit Lain rii MATl9�ta
_ - ,mama ■ I;� ft.I a...:.-..., aleatioglCooling Supply) C:c Water Supply(single) It It la. -
1 ia1 Water Supply(: ) -
Fedsl TO MA TRIAL EMPLACEMENT MEMO a AMOUNT
ft. ft_
Nos-W$er SRtpiq W i
—
IIlticketing DRecovery e. ft
—
Isrleetisa Well: ft. ft.
• Recharge ()Groundwater Remediabm --.. - - -- -
■ - •,f.- Storage and Recovery CiSafmity Harrier FROS6 TO NATIAIAL HNIP[.A[8@tismrHtro
Oft.ft. ft.
II _ Test.1:-.Lamm Technology °ice Control ft. ft.
t c-...-.,.- (Closed Loop) Unarm _. - - - -- ._.... .-- ---poke..
• ■ Rrbem) /�/O�or(elm under#21 Remarks) TOMOM • O ft_ o�a�7 / ` "heck 4R:a+i•rise,aeW
4.amen w s� - 2 7 Well ma [y/O ft- ft. .S .a c ,-cif
Sa.w (ev5 m 17 ft. tra ciA -
o�-e. sec/es 7 9 ft. sue$ !/�e. grare,i2ic Ye
> �(if &able) m ft.
7i7A rterr7A4 /f O. 147/in q 4
Physical ,City,and rip
c y past Idmodxatlon Na(Plr7)
Sh.Lades&and loegit de In degceesim es/aex�or decimal ddeegrees: —f .
22.
Wynn lintel tree belong is az�cir�) 7/ U w - o / D ry
&Ware)the w_ll(a or °•ea ary Sigisu re of Weil contactor Dmc
By.sivriag Otis fora,1 hereby ecru&that the nell(s)was(were)corsv..czed w accordance
7.Is this a repair to an existing wei: Dyes or ac with 15A NCAC 02C.0100 or 15d NC4C OW.0200 Weil Construction Sa usdm,ds and that a
rem b e rgdr,fill out known well onerous trite information and wplaia the Rums of the coP3'of this record has bet pemidcd t,the well owser-
repair ssedci21 remarks sartia.e or as the boat of this forte 23,She diagram or additional welt details:
&Far Gespnbe/DPT or Closed-Lasp Geothermal Wells having the same Yon may use the bade of this':%I t m provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details_ Yon may also attach additional pages if irtY eczaey.
drilled: SUBMITTAL INSTRUCTIONS
9.Total wen depth bel land surfs= ( -
ow (IL) 24a. For An Wells: Submit this form within 30 days of completion of well
For nwitiple wells at all depths ifs(err mpie-3@200'and 2@100') construction to the following:
IS.Static water level below top of casing: ziv (ft-) Divide&of Water Resources,Isthernastion Processing Unit,
,lamer lead is about casin&are..+" 1617 M. Service Center,Raleigh,NC 27699-1617
IL Boreisie dhmetes: gm) 24b.For beection wed hi addition to sending the form to the address in 24a
Air
t
12.Wen etioa method: submit of this form within 30 days of completion of well
to the follovrin&
(Le-saget,tatty,cable,direct per.et.)
Division of Water Re:aearrces,Undawaea&d Iajectiae Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Main Service Center,Raleigh,NC 27491-1136
13s.Yield(Elam) Method of test Air 24c.ter Water Same.A;laajection Weis: In addition to*""fie the form to
the addreea(es) above, also submit one copy of this form within 30 days of
Sneriene
13b.Diaafsellse type Amount 9 C 4V95 completion of well construction to the county health department of the county
whereconstructed_
Firm OW-I North Carolina Department of Enveroomealal Quality-Division of Water%sownes Revised 2-22-2016