GW1--04941_Well Construction - GW1_20240816

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Will Contractor Information.
Riney Coniher - 77.:7E.77-7--77-77-77-777
------
Wen Contractor Name -3A4g' le4dft. / �c (
j
2464-A00 /
NC Well Cceatactor Cettifinuon Number .
Frank A.Coniher&Sons Well Drilling, Inc. iROM TO DIAMETER TRICKNEss "'ATEIRt^t'
R ft. im.
Company Name 5-.
TO o
67 FROM
2.Well Construction Pit FROMu at. amcia ass rrt,:r i iu[, --
it
List all applicable well coasirudion perneiu(ie.UIC.County.State.Variance.etc.) I! R 70 ft- 6 v6 la' sOR-21 G we
3.Well Use(tbeclt well use): T 0 ft 7 ft' t S/ n. /. , et li- 1
Water Supply Will: • To DIAn4erER_SLOT si7E -txtccrrEss--MuTEetnL—=
•_ . .. . t ... .. . .lic R ft. is - -
Geothermal(Heating/Cooling Supply) 1:Residential Water Supply(single) R it. to.
Residential Watts Supply(shared)
FROM TO MATERIAL emetAcLater'?demon aAMOUNT
II Irrigation ft. ft.
Non-Water Supply Well:
t Monitoring ❑fiery ft_ ft. - - --
lnjeetioo Well: ft. ft.
I -•,�.- Rr.l,atg, OGrotuidwater Remediation --- --- __- .:.--- ---
■Aquifer Storage and Recovery QSal nity Barrier ,FROM TO MATERIAL EMPLACEMENT METHOD
• •,...• Test
0Sturmwater Drainage ft. ft.
■Expeannemal T °Subsidence Control ft- ft.
DTracer
FROM TO MON*ebr sad/rock type.gnie she,etc)
• ■Geothermal(Heating/Cootmg�) (explain under#21 Remarks) R Q ° �K'Cpd t/ V
4.Doh we9(s)Completed:1` �dl ID# �d R 5 it. `c 4cti C
5a. Location: ( R b"! R . SG'7 /' 4-6/
,e ewe ..S' f Lt. ( a q R XI 4/ue G-�e..);,/e
NameFacility ID#(if applicable) ft. R
Physical ,. . -...
c„unty Parcel Identification No.(PIN)
Sb.Latitude tend longitude in degrees/minutes/seconds or decimal degrees: ++� 1
(if well field,ate kat/iong is sufficient) 22. ._ �fi (7:
,- . 4..Z
42
N
6.b(are)the wen(a)0e ent or Drenaporary Signature of C eel Well Contractor Dane
By signing this form,I hereby ee.tify that the well(s)was(woe)constructed in accordance
7.Is this a repair to an existing well: QYes or QNo with ISA NCAC 02C.0100 or 134 NCAC 02C.0200 Weil Consnucitca Srm+dmds and that a
If this is a rep®.ffl our brown well construction information and esplain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form. 23.She diagram or additional wen details:
You may use the bade of this page to provide additional well site details or well
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-i is needed. Indicate 1U1 AL NUMBER of wells construction details. You may also attach additional pages if t>Prrssary.
chi SUBMITTAL INSTRUCTIONS
h 9.Total well depth below ad surface: C) 5- (n-) 24a. For All Wells: Submit this firm within 30 days of completion of well
For multiple veil,list all depths ifenfferent(eza npk-.3®200'and 2@100') construction to the following:
10.Static water level below top of fig: !O (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cm.) 24b.For Injection Wells: In addition to sending 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.Well construction method: construction to the following:
(Le.anger,rotary,cable,direct posh,ese_) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY/LLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) Method of test Air 24c.J,or Water Sootily&Injection Wells: In addition to sending the form to
S the address(es) above, also submit one copy of this form within 30 days of
13b.Dittmis�oa type: Sterierte Amount: & -- completion of well construction to the county health department of the county
where constructed
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016