GW1--01985_Well Construction - GW1_20240401

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WELL CONSTRUCTION RECORD(GW-11 F For Internal Use Only:
1.Well Contractor Information: ! 2024 1
Ricky Comher
Well Contractor Name •' v a vv v FROM TO � D>.el coi4 I
@t'c�c�cv,R CERTIFICATION PROGRAM /10 ft. lO 02 , ' °f
2464-A
ft. ft
NC Well Contactor Certification Number
Frank A.Comher 8jI Sons Well Drilling,Inc. �M TO - DIAMETER Tmt 4ATERIAI,
ft. ft I i m.
Company Name q (g ?V ___ .-.__ .' - r._
tff
2.Well Construction Fern*#: -FROM TO n!AMerER_ mint ESs MATERIAL -
List all applicable well construcfon permits(Le.UIC,County.State.Variance,etc.) .f--1 ft- /Crft 611/8 lu' SDR 21 we
3.Well Use(check well use): d tft' b3 It ')"Y in- f m C 1/
WaterSuppiy Well: • FROM --_ O _ DIAMETER SLOT stiz sit iiiiiiRu
Agricultural If ,'cipal/Public ft. ft. in. -
Geothermal(Heating/Cooling Supply) I ri Residential Water Supply(single) ft. ft. in., -
Industrial/Commercial • °Residential Water Supply(shared)
Irrigation FROM TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
' Monitoring °Recovery ft. ft
Injection Well:.
ft ft.
Aquifer Recharge ©Groundwater Remediation
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EtKMatEtaraaraon-`
' Aquifer Test °Stormwater Drainage ft. ft.
• Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer i'1=1.T.`VC WILT I '$i._f._.! - . t ''-. t -:4I
I .FROM TO DESCRIPTION(color, type..erain size,tie.)
Geothermal(Heating/Cooling Ret rn) [Other(explain under#21 Remarks) j R, 6 0 & bro cot J
4.Date Well(s)Com]plleteed:-//�5 (Well ID# -1 'C' / ,(s� k c- /—� �,�j
Sa Wen l ocatioD E 2J I 6-re f r O p ,- s, Y /05ft' / (�l"r e7_ �' 1(,itf(c;eca,v4.0 --
& 'A Pipe 5 ft. ft.
Facility/Winer , Facility Ilk(((if appl j/1d/2 f t R. ,
q ef/n s � ,; Coin �c ft. ft. i APR J 1 2024 _
Phys City,and Zip ft ft.
IJ1 rdL y'
County Parcel Identification No.(PIN) ,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.C ' n: -
35k el e/ , N 80s V3��gc W 3-/5-
..� L�
Signature
6.Ls(are)e)the W t re of Certifla Well Contractor 1 Date
wen(s) eermanent or °Temporary
By signing this form,I hereby cerkfy that the wells)was(were)constructed in accordance
7.Is this a repair to an a listing wen: °Yes or o with lSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that o
If this is a repair fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair raider#2lrer,mw ssectiionoronthebackofthisform. ..' ' . ' 23.Site diagram or additional wen details:
8.For Geoprobe/DPT or k2osed-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 l l is needed- Indicate TOTAL NUMBER of wells construction details You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below lurid surface: -_ I �' (ft.) 24a. For All Wells: Submit this form within 30 days•of completion of well
For multiple wells lint all depths(((different(example-3Q200''and 2Q100') construction to the following: �,
10.Static water level below top of casing: i 0 (ft) Division of Water Resotti,
ff water level is above casing,are`+'• 6 1617 Marl Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: I 1 (m.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction I i Air Drill above,also submit one copy ofithis form within 30 days of completion of well
: construction to the following:
(ie.anger,rotary,cable,diteetpusb,etc.)
i I Division of Water Resource!,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
• 132.Yield(rpm) Q; Q Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
SI the addresses) above, also submit one copy of this form within 30 days of
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13b.Disinfection type: sift' Amount: c ' completion of well construction to the county health department of the county
where constructed.
Form GW-1 I North Carolina Deem of Environmental Quality-Division of Water Reso teak i Revised 2-22-2016
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