GW1--03899_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.WA Caatrader lnfor ioa:
Kicky Corriher -- --- - - - __..1.FROM TO DISSOUPTIOP4
Weil Coatamar Name g lie ft. e27 ft. Is 9/
2464-A n s.
NC wdI Coreacior Certification Nicobar
Frank A.Corriher&Sons Wen Drlhng,Inc. M+ To Win■ • luckless
s. ft. is.
2.Well Csamaacciica Permit L consistence'per i e VIC,Cow.t.,State.Variance,etc.) / it' 6 0 ti' 6 is lai' SOR21
3.Wee Use(cheek well nod: ��'� 7 v n G 5"� $ j �
Water Sep*Welt PR014 - TO war ss k memo s iA i.i
■ .:...u.rn :r/rn alit ft. ft.
■ ( Supply) I`nk Water Supply(single) R. ft.
■ QRrsidmtial water Supply(shared) - — - —: -
t TO MAMMAL. DIPLA®mtr tame
■ ft. ft_
Non-Water Sspply Wei — —
■ ..:...,. _ Q y ft. ft. _
.., • Wait ft. ft.
■ Rage
Gaamclwater Remedialim --
■ •...,- Stooge and Recovery QSalinity Barrier mom TO trnTsarnl. FaffiJitftalftiff 111131oau
� � ft. ft.
■ ...- Test —
Subside nce Control a. ft.
■I- .._::.:_.:. Technology
■ c-..._— (hosed Loop) aT PR M To 1 '.:r..dc .
■ e_• ..- (Heating' Return) (explain under#21 Remarks) u✓ ttt. - , ft. oL_ 1}d
5-(� r wenIDll IQ a- a- S C
4 Dole Wel(s)Coapiele� l Q ft. 'c'.,25 ft. 4 . i.�4x
nlGk �A 1Y�0-1" �U
Sa.well Location: r
Facility IDO cif eppiimbie)
Soli`��� JUN 8 ZOt4
J1 i 'l- e /ra e In a. ft.
- City,sad Tap _. ._ _ ... --- -
Cematy Parcel Ideraificcrice No,(PIN)
Sb.ladtade sad inagKde is degreesiminutsixeeeads or decimal degrees:
(ifwea field,me lerftoee is sad&imt)
35, "7V9980 N I°, y70a3 / w 2� , i- v
Signaaae of - Weil Canoaes_r Due
ti Wine) waca
g3'Sig.ing dris forty.I hereby terrify that the well(t)not(Werth oawrtrreted in accordance
7.Is this a repair to an existing Welk DYes or I illOo with 15A NCAC 02C.0/00 or 15A NCAC 02C.t1200 Well Construction Standatir and din a
faits is a repair:AII ark blow well construction information and explain the nature of the eoPY(idea record has been Provided:u the well maven
owl,solder VI,aril section or as the hack of this forte- 23.She dam or additional well deras
&For APT erg C bsed Leop Geothermal Wells having the same You may use the back of this pap to provide additional well site details or well
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells
construction details You may also attach additional pages if necessary.
&Med Si7BMIiTTAI JINSTRUCT1OKz
9.Total welldepth blow land'Edam _/? completion 24a. or All Weft Submit this form within 30 days of of well
It For used*we fist all depths( -e it(amrpk- 00'and 2@100) suction to the folk:wing
10.Static water lewd below tap of ming: ,_...6--(/ (ft-) Divisors of Water Removes.Iftiorlftlitioft Pretesting Unit,
¢,rater lead c above casing,11Se 1617 Mail Service,Center,Raleigh,NC 276994617
1 L Borehole diameter: 2 (is.) 24b.For faieetlrn Wells: In addition to seeding the form to the address in 24a
Air Drill above,also submit one copy of this form within 30 days of completion of well
12.coal ceaad'sedaa mog sd; Mien to the following
(Le.awl,wary,fie,cbrect peak or-)
Division of Water Resources,Uaderg[uoad Injection Control Program,
FOR WATS&SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(a) 3 Method of test Air 24e.For Water Sylmar&Inleetlets_Weft In addition to the form to
y ''�� the address(es) above, also submit one copy of this farm within 30 days of
13b.nir kid. types AmoriAmoristI " CG,S completion of well coastructien to the cowry health department of the cotes),
where_
Farm GW-1 North Catohna Deportment of Environmental Quality-Division of Water Resources Revised 2-22-tol6