GW1--05803_Well Construction - GW1_20240926

111170
WELL CONSTRUCTION RECORD(GW-1) ( For Internal Use Only.
Wen Contractor : I
Ricky corms
FROM TO DESCRIPTION J
WellCa�arsor Ne ne ,7`2-3-1‘ r\("{f f' �;j 4
2464-A cc - 3 q c
NC Well Conizolor Certification KambQ
Frank A.Corriher&Sons WeI Dulling, Inc. Toft kid TIRCIMEns iiii.
Company Name ...--
L Well Construction Perrot r( A J-;ei„
br =,}.,a, �(/ ITTEt ,> MATERIAL
all pnht•well constrarlboetpU(Le County.Shore.Variance.etc_) ! / ft- !S'R 6 t6 — SD11-�t ..e
!
3.Weil Use(check well use)
Water Supply Wen: FROM TO DIAMETER SLOT SflL T>3cres MATERIAL
1,...",,,,,. DMtlnic l/Pubhc ft. ft
I (Heating/Cooling Supply) DResidential Water Supply(single) R It. t"■3� [ I Wad supply O
FROM TO - ---MATERIAL tri&4 �21T MEPROD&AMOUNT
'a ktigilDOn ft. r- R
Non-Water Supply Weil: ft. R --
t °Rxavcry — -_ 1
iniertin Welt R R
OtAqu""r Storage and Recovery Dsalinity Barrier PROM To . MATERIAL FdRr.ACIDECtfTMS3TIDo
wa Drainage
ft. ft.DAratiferTest — ft. ft.
�F�pe;2teertal TechnologyControl - ,: — --- .__ ,
3Genthecmal(closed Loop) MT — =-
��y,�� lam under#21 RemadcS) PROM--—-- ---- - °F�`YQ7' 7!'t fe ksies',i.il...t t�c.:eni.dude.et )
3Cieoeb.'(H�coaing Rearm) DOth (erp 0 ft. yi) it. �L Cl fi �/'
/ I R S/ R
4 Date Well(s)( - / Well lur# 17 7' 5) 't- S/3 7u e 11
Sa. Location: ft. R --r"'"-
4,,,e., ,, ,w4* , Cock
_- J ft.
ze
I / Pqr rf �'e L?0 Pr fl x 9.915,/, ft. ft.5" ft. ft. — EP 2 u 2024
11717/37f1 gIA
County Parcel Identification No (PIN)
Sb.Latino&and Magian&in degrostradnatesiseconds or decimal degrees:
or wen field,era Wong is sufficient) 0'-__0^ g 60
�a l
Signature of wan Cbolaaar Dsec
6.1i re)the wens t or
By signing this forth,I hereby certify that to weiks)worts(,we)coasarrsed u,accordance
7.Is this a repair to an egg well: °YYe s or t.o with 1SA NCAC 02C.0100 or ISA NC:AC 02C.0200 Well Construction Standards and that a
rein is a reps" feu out biome well construction information and explain the nature of the coPY of dun record leas been provided to the well owao,
repair eador 1E21 reworks sedtat or on the back of day form. jam..Site diagram or add:hinted wren details:
8.For Geo4rabdDPI'or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site devils or well
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells won details. You may also attach additional pages if necessary.
dn-Dcd: SUBMITTAL INSTRUCTioNSE
9.Told we'depth be'iaw land sue: , (N) 24a For Al Weis Submit this form within 30 days of completion of well
For mdriple wells list an depths j rfr$ermr(example-3.200"and 24 construction to the following
lti.Static water level below top of wing: 0 (ft-) Division of Water'Resources,Information Processing Unit,
ff water level is above casing"or"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole character: b.' Cta.) 24b.For Injection Wells: In addition to sending the form to the address in 24e
above,also submit one copy of this form within 30 days of completion of well
12.Well ooaNewetioa method: Air DriN motion to the following
(ire.anger,tooey,table,direct push,ate)
Division of Water Resources,Underground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center, NC 27�9 1636
L�. y Wpm) Method of testAir
24c.For Water Supply&Injection Weld hi addition to searlinF the form to
/ the adchess(es) above, also submit one copy of this fotm within 30 days of
13b Dhtadrx�o.type �eriene Ame..0 Cif)-S compi of well construction to the county health department of the county
whtae constructed.
Fan GW-I North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-2316