GW1--01921_Well Construction - GW1_20240325

' 11111117
WELL CONSTRttCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: - "' ;'--.
Ricky Corriher �.�,j�°►' ;�� '_
Well Contractor Name MAR
• ._ .__._ r _.IP.x,
®�� DI'ION_
2464-A 2 i:' 2024 I EMIT _ -- -
NC Well Contactor CapSptipn Number ""t`'^ h
Frank A.Comher&Sons Well Drilling, Inc. ��1 O `lei �i`1111 ---_.__ r_
ft. ft. I m. •
Company Name
2.Well Conshucdon Permit#: 302 t G vl Q !,t,} r - -
List all applicable well construction permits(La UIC,County:State,variance,etc.) VM soR z
J 61B ! �i t i cw 1.i x.� tKA7t3QIAI
t COMMIE
3.Well Use(check well use): tr R '� j/I-r,l / r
Water Supply Well < -
© s, ential lb ft. ft. 9n _—
Geothermal(Heating/Coolieg Supply) ir<Residential Water Supply(single)
lndustrial//Commerciat R R is --
DRardential Water Supply(shared) • -<• �—
Irrigation-: � -�
Non-Water Supply Well: ®�07.r.5r34:�r.��.;,.i.e.C■�,,a�i,,,-4c: r,,.t
R
Injection Well: D ye ft. ft.
Aquifer Recharge DGroundwater Remediation R '
Aquifer Storage and Recovery DSalinity Barrier 11:12 T. =�
Aquifer Test DStonnwater Drainage R
Experimental Technology [(Subsidence Control R R I.
Geothermal(Closed Loop) DTracer
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks) ��- -' �'�La'�+ = 'i 7T-=all
4.Date Well(s)Completed:3-1g—). well ID#
Mgr 9-1 ft s,4'
Sn.Well Location: t R $d r ,
Facility/Owner Name I ily110(if applicable �// ft. ft-
85 c` /<. g /cJl/�./7L(y ai7'(O EL R
Physical Address.City,and Zip �! R R
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I'
(ifwell field,
ve d,one lat./slung issufficient) D 22.Ce don:
35, (�3Qa Z7iZ N 80 3 t3 jJ ,o W - -
/19.;4t(7 3-16 -Q9
6.Is(are)the well(s) ermanent or ("TemporarySi of ed Well Contractor Date
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 with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair wider#1I reawb section or on the back ofthis form.
23.Site diagram or additional well details:
&For GRoprobplDPT or Qosed-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 aeressary,
drilled: , ;
/ , SUBMITTAL INSTRUCTIONS
9.Total well depth belowllatad surface: /-/ (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
For nadtiple wells list all depths((.different(example-3@20/00'turd 2 p100') Construction to the following:
10.Static water level below top of casing: t" (ft.) Division of Water Resources,Information ProcessingUnit,lfwtuer level is above casing.Use'+ 1617 Marl Service Center,Raleigh,NC 27699-1617 '
11.Borehole diameter: i (m,) f
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air Drill above,also submit one copy of this form within 30 days of completion of well
(i.e.anger,rotary,cable,direct push,etc.) construction to the following:
i I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C r1 'I Method of test:Air 24c.For Water Snooty&Infection Wells: In addition to sending the form to
I i copy of this form within 30 days of
13h.Disinfection type: Stterll ene Amount q ekes' the completiono of well , also submit one
of well construction to the county health department of the county
where constructed. '
Form GW-1 North Carolina '
Department of Environmental Quality-Division of Water Resources
-` Revised 2 22 2et6