GW1--03298_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only. 1111711111
1.Well Caatraewr :
Ricky Cortiher -_ ._ ---
PROM TO DESORPTION
weIICaottaraorName /0^6tt- /TG)ft- V ' C C
2464-A it ft. j
-
NC We9 Connector Codification Neer .
Frank A.Coniher&Sons Well Wing,Inc. MEM 1E11.11111. Minna
"a`r odirs NATURAL
R. ft. a
Compm,Nameyog 3o 71 -11111111.0111.111111 staisrat nomads MOM
Las s
L.wen G.ab+re e Permit KIM 6 is SOR-21
u appii�ablr well
peewit,(Le WC Co. '.00n) Softr'�.etc)
3.Wall Use(cYeck wdi arse): ----
Wider Supply elb (tin: �S' DiA w= 11:n.a...ANSI.:;...i;:mm.,ri,;itd
w 5�..,,'..:. ...lic ft. ft. al
in.
t _,v,-...- (ElesiingiCeolmg Supply) 1:d r. :..-... Water Supply(single) ft. ft. b.
■ ...... .. . DResidanial Water Supply(shared) — .. _. ...
PROM TO srATOTAL ","i.^....,..a"+...:.,.tT V.....wadi
■htigrtion ft. ft_
N.n-Water Simply WeltDRecf-wfTY ft. ft.
, _-• Welt ft. ft.
Groundwater Remodianou
.. •_ Stooge and Recovery OSaitty Barrier ->. TO .-_._ MATERIAL 15lrlfacassiott>a»
ft. It.Test riStomvemer Drainage —
MI ia.._::...•:. Technology DStirbssdeaceControl R ft.
a e- (Closed Loop) L1 race �o+w so Ems► �ar,.et�t►r1a )
■ e...._ ... (H oobog Room) (explain under#21 Remarks) con s. ,3 .1 ft. ry
�l «. " - ft- 5 C)
wee mrl •
3 7 ' v?Es & i -2- L-' 11 . r°
5. wen l.seatlan ft, et
►A n e:::a/'z°1' ft ft.
FacilityrOvnier le 1D*(f )
/sca cfci J' 1< 47. t -
-
Pkyset4sAikkess.Coy,am Tap Ot/‘
convey Paged btereireseina No.(rRtl —
Sr.Lsalt.de and wafnde i degreesinimbsieeeolads or deds.d dlsiraaa
(lf.wall sa4 wAoaes`J.oisc�) �j 7 a sat. •
35r .V00 !7 � N ';J_ / C/ w ����/ & /,94A-.-L .5` 020 �7
Signature of•-•.,-•wenCoanac►ss De1c
6.Wars)time wd(a /
�fv �t BY she this fora,I h.'s vow*that one~UN wrr(were)ca„atded it anooaime
7.h this a to an g we& L3•ea or ��a�'(1O xira 15A NCAC 02C.0100 or IBA NCAC 02C.0200 A'e8 Cmrtarcman Swank aid dirt a
y t a repair„fin oea know well coostractica aid co7Lete the,mtaoe of the Copy oldies renord has bead Provided an die wd1 ownen
repair ands VI mama motion or as tie Goat of this form- 33.Site dam or additional well details:
Geothermal wells having the same
caneOactiae,ady 1 Gw-1 Yon may use the beck of this pap to provide addition(well she details or well
S.Far Gespr ei elDPT sr t e deed. Indicate TOTAL.NUMBER of wells lion details, Yon may also attach ad3ttiaoal pages if terry.
is needed_
eeded_
&Med SUBMTI'TIL INSI'RUCTLOtt
9.Teed well del !!i below land surface (6 5 (f-) 24.. ger Ai.Weilic Submit this form within 30 days of completion of well
For mdripk,.d[r Una all depths¢creereat brosar,ie-344200'and 2®1007 construction to the following
10.Static water level bylaw top of easng: 3 0 (ft.) Division of Water Resources,lnfort.atia.Processing Unit,
s wear k,d above,ecas umr"--'__, 1617 Mail Service Center,Race b,NC 27699-1617
!IL Boren*diameter: LC' cm) 24b.For laid:den wells In addition to sending the fErm to the address in 24a
Air Dni above,also submit one copy of this form within 30 days of oomQktioa of well
12.Well es.sfraetioa seedbed: construction to the following
(Le.awe,rimy,calve,daact Ptah, )
Division of Water Roamrcxa,Underground Injection Cameral Program,
FOR WATER SUPPL1Y�WULLS ONLY: 1636 Mall Service Center,Rakich,NC 27699-1636
13a.Yield Wan / / c Method of test:Air 24c.P.m Water Sanely&Ilniection Wefts: In addition to sending the form to
the address(es) above, also submit one copy of this farm within 30 days of
13b.Dinleeties type» Asao.it C Q� completion of well construction to the county health deponent t of the county
where
Perm Gw-) North Cambia Department of Eevaaamental Quality-Division of water Resources Revised 2-22-21)16