GW1--05661_Well Construction - GW1_20240920

WET,',CONSTRUCTION RECOKD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mir
—
RickyComher • ..-A, --
Well Corrtractar Name
2464-A t S-4 ft. 2/I) ft. MEIVILI
Li6oft- li
NC Well Cumtractor Cora Numbs
Frank A.Con'her&Sons Well Drilling, Inc. =Dili—s.' V4I..-, IS;:,c..;:, `—_
Cow Name fj —
2.Wen C Permit#: 9 0 C' 9I 6 o ,;'A.;:,,r.,j j;.;... :«:, .
List a/applicable Kell constructzbn permit'(Le UIG County.State.Variance.etc.) M . �7 3 ft'
a 1/8 '° w slat ri e
eas 3.Well Use(check well e): 3 ft lffrigi /
Water Supply well: • _ _
0 , • .lie ft. ft. is
of Geot l(1r:vine/Cooling Supply) It'Residential Water Supply(single) ft. ft. 1n., --
DRtadential Water Supply(shared) , ;_.+ t .. -_ .
; i,^�� MA1 J/.1 .•„u.PC� u.1i .1 Irrigation
,., r.:e Ij7.1•,.'Jtaa
ftNan-Wad Supply Wes: ft-
I, mitering DRecovcry ft. ftInjection —
.
i WRe�ge °Groundwater Remediat oa 11111011111111
•Aquifer Storage and Recovery °Salinity Barrier 0litilliiii M.'rsaliv. a,x.s1 .:.,n„r i.,.,a
•AgoiMQ
Test DSTonnwater Drainage ft. ft.
I•ExperitgeMalTechnology DSnbsidenceControl ft. ft. •
t _•_.,..,.- (ClosedLoop) DTtarec —T'_.©-' = ° — •.-._` rr37I.T..
. t Geot�al(Fleating/Coolmg Reran) un n) DOther(explain dernsi ft. �1�#21 Remarks) 4
4.hate Weems)Completed: -1-S vrn / Well ID# Liu g- MallIEN
Sn Well Location: 7 J ft. BM" )i I-, Oc-
T®McI.S �/`()n.eX Mil �5 ' is /.. 6_) r� �-
Fa lOwnerName 1:M(ifapplieeble)
tt f.
(4,5 6a/ Nw7 55l.`A , ire:2 pc? D. ft.
Addtss,city,and� tt: ft t ^ s f
0cvt,77 a()I 0 2 g
County Parcel Identification No_{PIIv7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,maim/long is sr ) 22.Certification: .•r .r
35- 7693i2 N $o.5o,�297 W .... Q`// /� /�n„.�...,..z, D'fi-c„,2 / ~ a4
6.Ware)the wel(s ermanent or �Temporar9 Srgasuue of Ca t Vellll Connactoi,16I C hate
By signing the form,I hereby cr,tiff that the well(s)sea(wore)concreted in accordance
7.Is this a repair to an existing well: °Yes or o with 1SA NCAC 02C.0100 or 15A NCAC 02C.02to0 Well Construction Samdards and titre a
Phis a a repim facia known well construction information and explain the nature of the eoPY of this record has been provided to the well oWaer.
repay tench it21 renmLs section or on the bark of des form 23,Site diagrsffi or additional wen details:
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
on,only I GW 1 is needed Indicate TOTAL NUMBER of wells construction details You may also attach additional pages if necessary.
drilled-
P� SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface: 6 (h-) 24a.For All Wei: Submit this form within 30 days of
For ambrple wells List all depths V ervnt(ermnple-3@20[0''and 2@100') u�pp to the following: : of well
10.Static water level below top of casing: 7 0 (ft) Division of Water Re�ntces,Information Processing Unit,
iw°�lewd is above�,use"4,. 1617 Mail Service Center,Rale'eight,NC 27699-1617
IL Borehole : (l' (m-) 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 mod: construction to the following
(i e.auger,rotary,cable,direct posh,etc.) j•
Division of Water Resumed,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
A the address(es) above, also submit one copy of this form within 30 days of
13b.Dimon type+ Amount completion of well construction to the county health department of the county
. where constructed +I
Form GW-I North Carolina Department of Envuomnmtal Quality-Division of Water Resources s Revised 2-22-2016