GW1--02151_Well Construction - GW1_20240409

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only,
1111111.1711
1.Weil Contractor Inforrgation:•
I
Ricky Corriher :
weIICaiancmrName "u" trrroiv= - • — _
2464-A Mika o, .
NC Well CoorCertification N>m ft. ft' III
Frank A.Corriher&Sons Well Drilling,Inc. aga I a„ I n,r iar►'renui.- - ---
Cowpony Name
2.WF�Construction Pes�tIt: �OV / c - I_ ' l/Fit:1t- �i!,.: ;.._ iiii-rait-i-------
Zistanapplicabfe well contraction permits(ie MG County:State-Variance.eta) Ma y y 1t. .8118 1 ln. -zi pc
3.Well Use(check well used Li ft. L/L R' IrAW�Ot
MIIIMMil
Water Supply well:
■ . tt ,.'cipa1/Public r1i'i,`Tt. t' ■ r3 iit,ai-,!litE .�i�:i=1 rtiv.:iv1i
it. f
II Geothermal(Headng/Cooliag Supply) I.I r -.,:: Water (single) ft.
to.
' Supply ft m.
■ °Residential Water Supply(shared) :., ---- -- ---
i litigation
FROM
Non-Water -© .�•t. .F�. I I;ct l . y ' .n,i I
9w�: R. ft.
I: I
i Monitoring
QRecoVCry ft. ft.
t Reclrstge °Groundwater Remediatien ft.
■ .- Storage and Recovery °Satittity Barrier gErmiliiiiii
-- -- -—
. I Aquifer Test DSt�terMai� ft. I,• a
. ■Experimental Technolog, °Subsidence Control ft. ft- -
■
• (Heatiag/Coolirig Refmn) Other(explain node+#21 Remahs) �' s
yy yat111.7111
4.Date Weil(c)Complet 0Well ID# lIZECIIIIL762 , p■!
sa.wee l i'l' tie 4- go" ✓ram,- i -
Faef�rY/Ow�Naane Facility 1 �,n�r, ft. ft.owe I,eial rna5-I!rLan?mecpstrb,L�p/`e IIIIIIIIM
rm
Olvaa/r ami
,am t2374050 -.7- -
County PmoelM onNo.(P� _..... --- - lf;�;:r;.�`fir^'1?�. ^. li -_-
Sh.Latit•de and ita�ede in degreeslminoleslseoonds or decimal degrees:
( ram 3' `�7�' 6g�� 76
5 N W / og,,,„::.4 9--3-- .7
6.b(ane)tie weNs 40 or °T' y 1. Slgoabat of Gaud Well Contractor: n
7.Is this a repair to an ercisting welt By this form I hereby certify that the aell(s)was(tie)constructed in ace ordaace
°Yes or No witTh 154 NCAC 02C.0100 or ISANCAC 02C-0200 Weil Cons:a ction Standards and theta
lfthis is a++pain ftila,a b, ,will constrmuionWormwion and explain the astute of the °PY afads record has been Provided to the ell owner-
repo-mu/der
#2l remarks make; or on the Mack ofthis form..
fi.For23.Site diagram or addltioml w� ;sell
APT or�r 7tised=l;oap,Geothermal Wells having the same You may use the back of this page!to provide additional well site details or well
construction,only I GW i I is needed. Indicate TOTAL NUMBER ofwells construction details You may also attach additional pages if necessary.
�} SUBMr1TAL INSTRUCTIONS
9.Total well depth below4laid surface; g,, (g;) I,
Far mradiple wells Net ail depths¢therein+lerample-3®200'and AVM
co MI nstruction Submit this form within 30 days of completion of well
Static water
to the following:,
10.�a level i�v top of : _3 Q (ft.) Division of Water
above casing tee-+: 1617 Mail ServiceInformation N
lI.Borehole i �') Raleigh,NC7 .
Cm') 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well nretbed: Air Drill above,also submit one copy of this form within 30 days of completion of well
(Le-a teeny,cable,directpt b,etc.) •
construction to the following
FOR WATER SUPPLY*ELLS ONLY: Division of Water Reremrea,,U derg Injection Control Program,
.1636 Mal Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) - i • Method of test+Ate ,- 24c.For WaterSonoly&Infection n Welt In addition to sending the form to
136 D type S.4eriene Amount 3 f„/ ,,0� the also submit one copy of this form within 30 days of
a `Y/ completion of well construction to+the county health department of the county
• where constructed. A
Fan Gw-I I North Carolina Department ofEnvirotmmml Quality-Division of Water Resources Revised 2 22 7A16
If
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