GW1--01441_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW 1l For Internal Use only: • 7E1E111
1.Weil Cyr Information:
Ricky Corriheriiiw - —
Well ContractorName Eraf/J /tt:
INIIMISIONNIIIMIll
2464-A ft. ft. 1
- Frank A.CoRiher&Sons Well Drilling,Inc. tau t U
"„ " .III e[I:..{IJ-•`a
ft. ft.G / , I in.
NiimrAttpc. ©► ft�
6118 SOR 21 we
Litt a appfies:6k weircoo arspera (Le UIC,County:State,Variance, ) ���
3.Well Use(cbedi well use) 0,0 ft-
Water Supply Welk ittijililiIIMMIII )„I.s u-StVii;i;,, i I,1,.,i..: Ci.:, ',If.
■ . «I I,,.. lauPtiblic ft. ft. in. -
I Geothermal(Heating/Cotarg Supply) • ' Water Supply(single) R R in. _®
■Inclustrial/Coonnercial DReajd tialWaterSupply( ) _ --_- _ ..-"-
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'av_�_-- i -6,),i r,11]_i.,.1.RC ),u�.1.1l 1:e,,yev(•..•eel
II inigition ft. ft.
Non-Water Supply Well
Wed DResoyety ft. ft.
•
Stooge Recovery D Rtthatr�
©© Y - R.;.I:a.• ,irsui.,e.., .�
■ DstormwaaerDrainase ft. ft.
■e a.. „,T Technology DSnbsid ice Control ft.
--- .ft.
• (Closed Loop) DTI let lliiiiIii.L a „is_:_.�L - te
■ .,_ (Heeiop/Cooling Return) ChOtherIexplain under#21 Remarks) e3 R Mil 1211 INIP
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4.Date We l(s)Completed:off^1 / Well 1D# `� ft. �� _ l_—
IM—
ft. ft" 11111111112MINKOMEM
/ /ml �rNarne v d 41/.- R R
Fac
_ Facility ID#(ifappl clble) -
6
\ ' I k'0-5- gei3O' er W Ci /���in ft. ft. 111111111111
IIIIMIIIIIIIMIIIIIMPII
1PbyspAddress.City,and R ft. - -
Q0,,,,,,/
..
c„ 62
Cody Parcel Ideas n No-(PIN)
seconds or decimal degrees:
Sb.Latitude and lei is�''��
(ifweUSeld,we sue) 22. ' .
35 66- .5. O N 80 , 3 i8 23 / w ' ,0 Ze24.4....j„,
fCatrfs ell Coauacto Date L
6.la(are)the weR(43(enisamest or OTemporary f
BY signing this that the wells)was(were)constructed in accordance
font:.I hereby co+rfy.
7.1s this a repair to as existing we Dyer or bea with 15A NCAC 02C.0100 or ISA1 NCAC 02C.0200 Well Construction Standards and that a
copy old*record has besot proveidd to the well owner.
ljtkia Is .fill ow known>otAmavvcdos information and explain the'ulnae of the I
repair solder OM renori tsection or on the back oj this form. 23.Site diagram or additional well dam:
8.For or Closed-Loop Geothermal Wellshaving thesame You may use the back of this page to provide additional wellsite details or well
construction,only 1(iW-I is needed. Indicate TOTAL NUMBER of wells consttuction details You may also attach additional pages if n ce sary.
drilled: O - SUBMITTALIN‘r'RUCf1ONS
Total9.To below land surface: (ft.) 24a.For AUWells: Submit this from within 30 days of completion of well
For amid le e> depths tjdffoert( 00'and 20100') construction to the fDllowinx
10.Static water level below top of casing: 3 0 (ft-) Division of Water Resources,Information Processing Unit,
Ij,nter lard a above easing,use-+~i, 1617 Matt Service Center,Raleigh,NC 27699-1617
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1L Borehole diameter fr, (iea.) 24b.For Iniection 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 method:d: construction to the following:,
(i e.anger,rotary,cable,aired push, ) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gems) Melhed of tu74t:Air
24c.For Water Saooly&Infection Wells In addition to sending the form to
the address(es) above, also'submit one copy of this fors within 30 days of
13b.Dist : StetBene AmountGC S completion of well construction to the county health department of the county
where constructed.
Foam GW-1 North Carolina Department of Envuoua mml Quality-Division of WaterRIesoiaoes Revised 2-22 2.016
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