GW1--02191_Well Construction - GW1_20240408

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WELL CONSTRICTION RECORD(GW-1.) For Internal Use Only:
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1.Well Contractor Information:
Ricky Comher '
-' ittftifiniffii•-• iis-cluiiiiii
Well Contractor Name ,
2 "Ma 1 Vat. IIUZArnIMMIIIIIIIII.2464-A .
NC Well Contractor CatificatiOn Nimiber •
Frank A.Comher&Sons Well Drilling, Inc. s±liseiiltimlimi
ft. ft. m
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Company Name
3c79 77
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2.Wen Construction Permit it:
List all applicable well construction permits 6.e.UIC,County.State.Variance,etc.) .-i-t ft• EMI 6 ifis ! 'III SDR-21 ove
3.Well Use(check well use): .3 ?. 39 ft- EirigIVATMEMElli
Water.Supply Welk
litttilibliffi3Agialilitfttrktin-Tafiti ski" illi i;rcel;I:r.NjOlifirTii)'I/3 iall D .cipal/Public ft. ft. in.I'
Geothermal(Heating/Cool liag Supply) hesidentia1 Water Supply(single) ft. ft. in.I '
industrial/Commercial Residential Water Supply(shared) -- --.-.- -- •-e77..w.t•„.;•,-,- .-:,..-.__-_-.. 1.,.--• ,_ =-- = -.-:::,;,----t--ez: •
Irrigation 1 ijitiiiikifia--- -iMilii-F,17:16;;EI;7,4-Ti;c:t;fili7.ia
Non-Water Supply Well: ft. ft.
' Monitoring .
. DRecovery ft.
- Injection Wen: -
ft. ft.
' 3Aquifer Recharge DGroundwater Remecliation I
Aquifer Storage and Recovery DSalinity Barrier 11±71BINBIE IIMUMBIIIMIIIM I,/;,1;,'Ijig..<1.‘111,',1 4 j:to);1111.1. '
' jAquiferTest DStomlwater Drainage ft. ft. I; 1
• Experimental Technologi " ()Subsidence Control ft. ft. I. ,
Geothermal(Closed LooP) DTracer
'-I I fffll I 1 liffibta al.1'-'C: E.7.1.- 7 Geothermal(Heating/Coo'liag Return) DOther(explain under#21 Remarks) # r3
0- ft. NiMAIRMSEN1111111111111
4.Date Well(s)Completed3-g‘..- 9rWell ID# EIREILINIIN _111WMPRWirLt.jMMIIMM
5a.Well Location: =LIMA AIIIRTM• alffltirs..""Milill
4-ray Dapir5 • . ft. ft.
ft. .1111 MMIIIIIII.
Facility/On/flea-Name
Facility ID#(if applicable eta ft. =ME
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1714P_6.CM;//16/4e Al()leo,/at ci. ft. ft. ! .
Phys' Aildress,City,and Zip 1 f' ;-"_;-1-.7 P'7'':- -'.2:2;U:IN
171614,4.4 i 000.0 '7V
TCounty Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,coe hr/l is sufficient) 22.Ce lion:• ' -
35.7 63 4(6 eg N 8°0 CV6' / 7 a
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Signature of • Well Cormactor Date
6.Is(are)the well(s)permsinent or 13Teinporary
1 By signing this form.1 hereby certify that the well(s)was(were,Iconstructed in accordance
7.Is this a repair to an emoting well: (3Yes or No , with ISA NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and theta
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if this is a repair:fill onaosossit well mins:ruction information and explain the nature ofihe copy if this record has been provided to the well owner.
repair wider#2I rentarls section or on the back of this form.
- 23.Site diagram or additional well details:
8.For G robe/DPT or 6rsed-Loop Geothermal Wells having the You may use the back of this page to provide additional well site details or well
eoli same
construction,only 1 GW-1 lis needed. Indicate TOTAL NUMBER of wells construction details- You may also attach additional pages if ne"gs"Y*
drilled: i ......---
SUBMITTAL IN .STRUCTIONS ' •"
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9.Total well depth belowliaid surface: R5
(ft-) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple urns list all depths ff different(example.3@200'and 2@100) construction to the following
10.Static water bvel bekiw top of casing: (.0" (ft.) l'
Division of Water Resources,Information Processing Unit,
roaster level is above casing.itse"+"4.F. ' 1617 Mail Service Celp4r,Raleigh,NC 27699-1617
11.Borehole diameter: 1 (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
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' . I I Air Dn 11 ,above;also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: i
(Le.auger,rotary!,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 1 4/ Method of test Air 24c.For Water Snooty&IniectIon Wells: In addition to sending the form to
1 i the address(es) above, also submit one copy of this form within 30 days of
131).Disinfection type: ste, rene Amount 3 cats completion of well construction to Ithe county health department of the county
where constructed. I.1
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Form GW-I . North Carolina Department of Environmental Quality.Division of Water Resources; Revised 2-22-2016
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