GW1--04587_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only 1111711111
L Well Contractor Information:
Ricky Corm FROM _TO DESCRIF2464-A T5O l
R R
NC Well Color Certifi Number
Franc A.Corriher&Sons Weil Drilling, Inc. PROM To DIAMETER MATERIAL
R R in
Concemy Name
17)2 2 --- ----) c
J ROM TO DIAltS[�t_ l> !tA'�IAL
2.w Ceatatredlsa remit#: /_ J J
Lena applicable well construction permits(ice.UIC.Cao,sy Star.Variance,etc-) 1 i 8- ( C�' ft. 6 u sat�2t ..c
3.Well Use(tileek weH red c,p ft U )tc, G.�/ -m, /5 j ,l tz f
I Water SupplyWell: FROM To DIAMETER SLOT SI= TeiaQus86 st+TEituL
( C &tpply) I.I I, Wane:supple( ) ft. R tar
■1: -, Wad Supply(shared) FROM TO MATilW, D1PLA(811�'R'atI:IHOD&AMOLiNT
Non-Water Supply Welk I ft. R.
1. DRecavay R ft.
Worthen Welt 1 R R.
OGroundwater Remediation
■ • .."„- Stange and Recovery OSahmty Barrier FROM T
To MATERIAL EMPLACEMENT METHOD
ft. ft.
Test CiS — —
a t• .. Technology t..T Control ft. ft.
■ +w+t,.ssxut(Cioeed Loop) ErTSCes PROM o�� ►edaess, �gq c�see,oe)
■-..vrp+.n..»1(Heating/Cooling Return) 9 er edam�r#21 Remaacs) L, ft. c1 s_ ` J --
4.Dale We )Completed:67 -Q wen m# tr- t/U tit., ✓i. s�/ Ave_ �—
`�U RJn2?R �/
Sa.7 Lacer
777
ime Fatality LW cif applicable) tL S. ♦ f
t� R /TheArr_..5�/i/e' / % ft. ft. b .4
Physical Atid7 City,anTsp
/ 3g R R (o2a
County Facet heron No-(PIN) t,
Sb.Iatit-de and Ida in or decimal degrees:
-
(if seen field,37%�) �oY3�� w C.-17-2y.
�- ; 2
,‹ ifrir12
6.Wane)the wells) t or DTenipotary
Sigomne of ised well Comzaaor Dme
i' By signag Mil farm,1 bere6v cent'that the wells)aim(,sere)constructed in aocordence
7.Is this a repair to an existing welt QYes or F; '.1 with ISA NCAC 02C-0I00 or ISA NCAC 02C.0200 Well Constructor r Staadmtir and that a
Ifdss is a teem.fill oat blown welt construction infon„asioa and explain the nature of the COPY 0idrs record has been provided'to the well owner.
repair,mds i21 remarks social or on the boar re-this fore. 23.Site diagram or additional'cell details:
You may use the back of this page:to psovidc additional well site details or well
S.For Geepro or Ginned-Leap GeothermalWells having the same details You may also attach a�tiaoai pages if
onlyly I 1 GW-1
W-1 is needed Indicate 7�OTj4L NUMBER of wells 9-
construction,daub l r C� SUBMITTAL i isTRUCTIONS
9.Total wee depth below load surface: / t) `' (a-) 24a. For Al Wefts: Submit this; form within 30 of
Far,adtiple wells fist ail canes VoWer�a(arm sple-3@2000'and226100') boa to the fallowing days completion of well
lY Static wader level below top of casing: (f (ft.) Division of Water Resources,Inforination Precessing Unit,
router kart is above casing,,use`*" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole�mota- f� cm) 1 24b.For luiection 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 Waft eeapatrttefiaa toothed construction to the fofowittg
(it.eoget,tatey,table,&Nett posh,etc..)
Division of Water Resources,Underground Injection Coral Program,
FOR WAIRR SUPPLY WELLS ONLY: 1 1636 Mail Sirvim Center,Raleigh,NC 2769 9-1636
13a.Yieid(o) may,( Method pf ter Air 24c.For Water Senuly&1n tIos Wean In addition to willing the form so
the addresses) above, also submit one copy of this farm within 30 days of
Marlene
13b.Db�fa°ea type "minta Cif") oonettxion of well constructuin to the county health department of the county
where constoc tap
Farm OW-1 Notth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016