GW1--02471_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD(GW-I.) Far Internal Use Only:
1.Weil Corinne:tor Information I 1
Ricky Corriher •
iltffiaiiii -
Wen Connector Nei=
Mal OK"
2464-A IMIGNIIIIIIIIIIIIIIIIM
2.
ft. ft. 1
NC Well Conenetor Cr:UW=1111On Number • L
Frank A.Corriher&Sons Well Drilling,Inc. tifilliliiiiftfili56.',4 v,.iiiiiii--;,';v,;,•1111 iikriitai-
ft. ft. 1 I
f0 in. • •
company Name
2.Well Construction Perink#: U 1 3 I- MOM 02...111Mi'lf.v1••••:+•1111116 r:,:•.f•O-,,1111 tirtilifAL
List all applicable reel I constronpennur(ie.UIC,C.aunty,State,Variance,eta) =aril= 6118 ' in. SCR-21 PIC
3.Well Use(check well me):• inglarianIZSMIIVATIVI C-"
Water Sapply Well: .
•
inmiiiiiumiolizi.1, iriAIIII:10:1,sizir,:lilar: ::.,:i...-: - , —•"-.'
0 •..-cipal/Public ft. ft. in.
II Geothermal(Heating/Coiling Supply) iN I'-'.-.., Water Supply(single) ft. ft. :ba•
II lodustrial/Cominercial DResidential Water Supply(shared) 7 ' .,
II Inigation bifftmlilLimmilm-rryniTI.. . •:.•r.,,c 1:1::Lc.rrN..;;,11:41
,
Non-Water Supply Well:: ft. ft.
• II Mcmitraing DRecovery & ft. 1
,
_ _ .• Injedion Welk _ . .
ft. ft. ,
I •,.,-., Recharge : DGroundvrater Reniediation
a • ,,,-,- storage and Recirvery DSalinity Barrier 11=M1111ilEcimilim tdAtiltiu. II:.,',t ,,T.:-.i.,Q,ir I ti y:0;,111.1
II Aquifer Test DStormvrater Drainage ft. ft
• . II Eimerintereal TechnologY DSubsidence Control ft. ft. I -
111 •-••,,.- — (Closed Look) Mincer
• li- Illiff—111Iiii.-1 - LAL..--- ;-__::L-4 ..:2±1:-- iiii
ft _•,.„. (fleadfteco6glig Return) nOther(explain under#21 Remarks) mu 1-0 . irmargyp2Amoinn
4.Date Well(s)Completed:
q-i- .gtle
• Well BM MilIPMECIIIMMIMAPIPMENIIERIE
Ss.Well Location: IIIMMIIPMI e,
-tr7Will=11111MENIIIIM
3 ffh n 14.4450 4 MaliErigwiffirr;M.Ng 4__.,.Miiiiimil
ft.• ft.
Pacnity/Owner ..NInE,., Drafty ID#(if applicaheltrve3 ft. R.
.' -70/ "-r r Aiel
an k rr afde a arCP ft. . ,
Ph Address,Qty,and Zip ft.
/<0 it•-4 4 116 9a3 9 .. _ ._ •. _•
County PmeeildeaitheitjonNo.(PIN) . A 2 20
PR ,
.).
Sb.Lakin&and longitude in rkgrees/mineteskeconds or decimal degrees:
•
(Windt field,ow Mt/long is sufficient) ' :
fif, 4.tig 78 80• g3 / R
•T W 22. . Infc7;7ar. '.0;
35 e, ";0,;(1'...:3::3•1_,'W!(2,
Signature Of certi4 well Contract=li : Date
6.Is(are)the weil(s.U.'I'eminent or DTernporary
P 1
By signing this Ann,1 hereby cern"thatthemell(s)INV(were)contacted in aormrtkosce
7.1s this a repair to an Mlstin well: DYes or Ni, with ISA NCAC 02C.0100 or ISA NC4C 02C-0200 Well Comaruclica Standards and that a
Phis'is a repainfill ont bowl well construction&formation and explain the nonce of the PoPY of this record has been Provided b':)the Well OWnen
• repairunder#21 ranasks sectlon or on the back cilia font:.
23.Site&nem or additirmal well details:
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You may use the back of this page to provide additional well site details or well
&For Geoprobe/DPT or Oosed-Loop Geothermal Wells having the same
construction details_ Yon may also attach additional pages if necessary.
construction,only I GW-1 his needed. Indicate TOTAL NUMBER ofwells
drilled:
SUBMITTAL ocrioris
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9.Total well depth befell/11dd surface: 2 9,5-
(ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For:radii*wells Net al I depths&Oran(example-WOO'and 4100) construction to the following, l'
l&Static water level below tap of ciulug: ?6). (ft.)
Division of Water ResOurces,Information Processing Unit,
rooster level is above casing Use'+" 4
1617 Mail Service Center,Rakigh' ,NC 27699-1617
I I
IL Borehole&uncle= i 00.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
_11 Air Drill above,also submit one copy of this form within 30 days of completion of well
12.Well construedan method:
construction to the following I
(Le.auger,rotary,cable,dizectpash,etc.)
r 1
Division of Water Resourees,Underground Injection Control Program,
FOR WATER SUPPLY*ELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
r :13a.Yield(gym) .i/ Method of tette Air 24c.For Water Sunuly kk Infection Well= In addition to sending the form to
1 1 the address(es) above, also subthit one copy of this form within 30 days of-
13b.Disinfection type: qterkne Amonne 3 A ao"._.g completion of well construction to the county health department of the county
where constructed.
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Pone OW-1 . North Cara of Enviromnental Quality.Division of Water Resources , Revised 2-22-20I6