GW1--00165_Well Construction - GW1_20231229

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• WELL CONSTRUCTION RECORD (GW-1) , For Internal Use Only:
1.Well Contractor Information: '
Ricky Corriher . :A4..WA'ER'ZONES` _, . ,..,_,N4' • o.,,, •
FROM ,TO DESCRIPTION
Well Contractor Name
2464-A 44 ft. 71'rt. ,S�
NC Well Contractor Certification Number
, 15.OUTER CASING(for,multi=cased wells)OR LINER(if ap licable) a.
Frank A.Corriher&Sons Well Drilling, Inc: FROM TO DIAMETER! THICKNESS MATERIAL
ft. ft I :in.
Company Name3q7 /y tr
'16.INNER GASING OR'I'11BINC'(geo'therinal'ciosed-lodp)
Z.Well Construction Permit#: FtROM TO DIAMETER' THICKNESS MATERIAL
s. List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) rr'l 'IL ft. 6 1/8 I� ,tn• SDR-21 PVC
' 3.Well Use(check well use): eV it. �f[. ' i1n. /c L`� Q Cd
_I7.SCREEN,.ti , ..
�J \
��((((��� l Water Supply Well: _ . ... _ _- • a , _ •
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL ,
_ • Agricultural ® unicipal/Public ft. it. in:,
I
•
Geothermal'(Heating/Cooling Supply) fr Residential Water Supply(single) ft ft in
l
Industrial/Commercial t, DResidential Water Supply(shared)
Irrigation • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ft. ft. 1
\ Monitoring Recovery • ft. ft.
• Injection Well: . . _ __._ _ -
ft. ft.
• Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
_Q Experimental Technology 0 Subsidence Control It. it. i'•
Geothermal(Closed Loop) OTracer, 20.DRILLING LOG(attach additional Sheets if.necessary)-
. ..� FROM TO DES RIPTION(col r,ha soil/rock type,grain size,etc.)
ty Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) D ft. �� tt. .e�� i�
v //'' / G� U
4.Date Well(s)Completed:f ot�•-1� 3 Well ID# �v ft. ft. p� 1�-e.�(A K
5a.Well Location: s� ft. 3 1: Q !icte- Fr2 .
/`L 'idt cAI a, pain 9e ft. ft. I; �� ...:'
P 9 : k..
Facility//OOwnerNa/me / Facility ID#(if applicable) It. ft.
{V 2023
ele4
Physical Address,City,and Zip- ft. ft It, •1 • '
l l 1
gO'ttrt7.4 '7 fof 21.REMARKS. _ . _ r � •c; k ,.
L
County . _ Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal.degrees:
(if well field,one lat/long is sufficient) ' `� 22.Certifi tion:
35F7iI
Q � / N 80(J t� r � w i 62" . . J9�-�-- ?
Lili
` 6.Is(are)the well(s) Permanent or Temporary Signature of Certt tad Well Contractor Date
By signing this form,I hereby cert fy that the well(.)was(were)constructed in accordance
- 7.Is this a repair.to an existing well: DYes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the ' copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/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 ).
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsonecessary.., attach additional pages if necessa
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
,For multiple wells list all depths if different(example-3@200'and2@l 0') , construction to the following: '
10.Static water level below top of casings (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: in. ,-. " t
( ) 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: I, '
(i.e.auger,rotary,cable;direct push,etc.) - I ,
Division of Water Resources,Underground Injection Control Program, -
FOR WATER SUPPLY-WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ( . Method of test:Air " 24c.For Water Supply&Iniei'ftitin Wells: In addition to sending the form to
' the address(es) above, also submit one copy of this form within 30 days of
Sterilene, , �'
13b_Disinfection type: Amount:D 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
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