GW1--03932_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 11117110
1.Well Casdrader lsform:tios:
Ricky Co # r .. -- ._ --
mom
TO
DIMOCRIPTION
i eaunwrem . 9/i-g. 2/5_ft- 3 d 5 a
2464-A et. s.
S. NC Weil Canmeor Coal:maim Flambee
Frank A.Corn'her&Sons Wei Drilling,inc. tOoar TO
DUKE= T9saaft115 MAT AL
Company Name
L.wd CacrnC$K PPermitd 3 6a0Millala61R SOWN nc
Lau all applicable well adwerbrb ron P�� CO .ay�CO �Y•State.Yarrm.oe,etc.)
ginlialiMILIPPOr
3.Well Ilse(check well woe): f - - - —
Water Stgtply wen: ,-TO ntAatelta nor amMAT L
:.: `.. R. ft.
-, Sal he iv.
■ ( Supply) ,a :.,-:.._,,:., Water Supply(single) ft. ft. la.
>. IIdmtial water Supply(shared)
3 iummi MA1'®t1AL fPucrOMITaoo£,+MovKr
tL
.NowWster Simply wen
Recovery ft. ft.
v Weeded W- ft. ft --
Grou dwater Remediaton
s. U Storage and Recovery OSSMity Barrier i=31013atilMillii a ATT L .- -. -ii •,...• ..r ,1 u .,-
DStormwater Drainage ft. ft.Test - .
n ■�• • ':. .,t Technology ['Subsidence Control a' ft.
' ■ e-....-...- •
(Closed Loop) D PROM TO ardor- . sMselktas„lahis,,ar.1
■ c (H CooGag Return) Dr her(Main w,der t$21 Remake) 0 a. .tiv a a� .
__ , 4.Date Wd(a) ~/e-2 `well MS 4/0 IL 69 IL iL 6 y7 l
Afr-
Sa.Weil Location: e' s, I y ¢, �l
--:3-in CO,hPr 0Se� •
al _e— ,:-•S _
Paul*roll(if eppgadsiv L3, " t._ i.
F5 s�ori rden Lan eigac%wd/ . R 9it.
n Ey
9) 379196139 ��.(: -_
,:y County
rro spun
—! Sb.lsrlmde and M. ttade is degrees/minutes/seconds or deal doggies:
Brava fiold,as Iting is a>Milos)
zz
0 35�53 -7 N 8/3, yet 02 33 W 77:
- 5/sgaae of Cn�w�C.unaoar _15me
e,IsPint)the wel(s)43‘111111•11t or OTC
ch By signing this foram,1 hereby car*that the wigs)was(were)onerous d its annoniasar
7.Is this repair to as existing we& °Y i or wick 15A NCAC 02C.0100 or 15A NC.AC 02C.0200 Well Coabactlon Sleaadants mod car a
and the nature of the ooPY of record best provided to the well owner.
Enterer u a rgaav�i ma bsesiG well arrstra�O.r explaaa
repar.oder ill,soria.umoa or on µe back aj nos form. 23.Site pram or additional well wtetats.
S.For GeeproidDPT or Cieaed4. op Geothertaal wens having the same You may use the back of this pag:so provide additional well she details or well
n,only 1 GW-1 is needed.. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if trt ssffiy.
ainstructiodrilled_ SUBMTUAL-INSCRUCIIONS
9.Total well depot below bad aefac= (B-) 24e.gee AR Wel* Submit this `corm within 30 days of completion of well
For dtlpie wdlr liu all depths s f rfiffirent(erie-302 /4y 00') construction to the following
10.Static wain level beam tap of casing v (ft.) Division of Water Resrarsxa,Information Precening DM,
runner ind is above costa&m -+-, 1617 Mai Service Center,Raleigh,NC 276994617
1L Borehole diameter: (. (m) 24b.For taieetios Wells: In addition to sending the form to the address In 24e
Air above,also submit one copy of this form within 30 days of completion of Wei
12.Weil emafrt etisa method: Drillcommuctian to the following
(Le.®tom,may,cable,direct push,ex.)
Division of Water Resources,Uadergretud Injection Control Program.
FOR WATER SUPPLY WILLIS ONLY: 1636 Mad Service Gager,Raleigh,NC 27695-1636
13a.Yield(Ww) (2 Method of teal:Air 24c.for Water Senoiv&1aie w aells In addition to sending the form to
the address(es) above, also submit one copy of this film within 30 days of
13b.Disiafeetdaa t� Marlene Ameat C(314j--5 oompletion of well won to the ooanty health department of the county
where constructed
farm GW-1 North Carolina➢epattrrnene of Environmental Quality-Divsioe of Wiser Resour es Revised 2-22-2016