GW1--04480_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only. 111171M1
1.Well Contractor Information:
Ricky Coniher
FROM_ TO fTION
wen Cattmcror Name i 5 it. '7, 3 5 Q/
2464-A ft. ft.
NC Well Contactor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. PROM ft. ro tz DIAMETER taaa5FS - MW AL
Company Name I
2.Well Construction Permit#: J 3 I FROM �T/O Mamma ,tee MAr®uA.
List all npp1i-ehl<Weil construction pennies fie UIC.County.State.Variance.etc.) �'/ ft' ` �' 6 1B SCR-21 P.c
t `-2 ft y.2- it. s/ / 7
3.WellUse(check well use):
Water Supply WeB: FROM TO DIAMETER SLOT st7E THICKNESS— MATERIAL
• •_ ' ,. . t . .• ipalfPublic ft. ft. in
■Gwthermal(Hcating/Cooling Supply) L Residential Water Supply(single) n ft. to
■ DReadential Water Supply(shared) -
FROM TO MATERIALEMPI.AC IT METHOD a AMOUNT
i irrigation
ft 1t
Non-Water Supply Well:
$Monitoring ORecovery ft ft. _ -
Injection Well: ft. ft.
■ -.,... Rage (]Groundwater Rensediation - . . .... . . ..... - - __.
■Aquifer Storage and Recovery DSal nity Barrier FROM To MATERIAL EMPLACEMENT METHOD
A�� 0Stormwater Drainage ft ft
■ Test — -
IS Experimental Technology 0Subsidence Control tt ft
is :_.., ..-- (Closed Loop) DTracer - ,;
Return) �Otba(explain under#z l Remarks) FROM TO o rues(eater drills,raairToek tr.t:EroM vine.,ea.)
■Geoa�mal(Heatiag/Cooliaa 6J R- j ft /L�L.1 ���_
'3�) R `> ,Z ft- SG ��- G�C_ -
a-Date Well(s)Completed: � J�or?"� eu ID# y / F
se. Location: n. /6.3-ft. � 1f-i✓.C 1
�' t� re. T 1 tl
) A )er ft. ft. JUL 3 a 2024
20,(rifyr.94 (if. t.)
R. ft.
+7 SO ChE� Try 0/ // �„ ks►•,!� 4,
fL ft ��,: 1 Likk
Address,racy.a�� a' -
County -
Parcel Idetgi5cation No.(PIN)
Sb.Latitude and longitnde to degrees/minutes/seconds or decimal degrees: -
Orwell we latflong is sufficient)N ! / W 22.
7
35
a/ ,,,,,,X, -)- .)-02y
6.blare)the weg(s es�t or OTeniperary
Signature of Well Contractor D1ene
By signing this form,1 hereby co tj that the.eell(s)awes(were)constructed in accordance
7.Is this a repair to an existing well• DYes or r2,,( with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Coarnttcaoa Standards and that a
If this is a repair.fill out brown well construction ittfwmarion and explain the nature of the copy of this record has been Provided to the ere!l owe.
repva under#21 remartr section or on the back of this form.
23.Site diagram or additional will details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this cage to provide additional well site details or well
construction,only 1 GW-1 is needed_ Indicate TOTAL NUMBER of wells won details. You may also attach additional pages if nePoscary,
drilled: SUBMITTAL INSTRUCTIONS
9.Total we depth below laud surface: 1 'i2-/ (n-) 24a. For AB Wells: Submit tilts form within 30 days of completion of well
For multiple wells list all depths if different(¢sample-t(o)700'and 2@100') cottsttuction to the following:
10.Static water level below top of casing: 3 v (ft-) Division of Water Resources,Information Processing Unit,
1f wiser level is above casing,are"1 7 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cua.) 24b.For Infection Wells: In addition to sending the form to the address in 24e
Air Drill above,also submit one copy of this form within 30 days of completion of well
12.Well comtrnctiea method: construction to the following:
(i.e.as,rotary,cable,direct posh,etc.)
Division of Water Resoarcev,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2769 4636
13a.Yield(gpm) 30 Method of test:Air 24c.For Water Snooty&L�ection Wells: In addition to oohing the form to
the address(es) above, also irbmit one copy of this form within 30 days of
13b.Dis os type: Stele to
m> Amount 4-2 C `/S completion of well construction to the county health department of the county
where constructed_
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Rc:omces Revised 2-22-2016