GW1--00996_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. Mir
1.Well Contractor Information:
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Ricky Corriher - --- ---- ---'— __:—__-_._
13 tiiiiiii .....,,..♦
Well Contractor Name pQO B. Oft. U%
2464-A ft. ft.
NC Well Conti Certification Number • .
- Frank A.Corriher&Sons Well Drilling, Inc. iitf-tt""',wilt"t""''x\ _
fft
;� ii i6-r`Zia In.
Company Name /' ��
2.Well Construction Permit#: 3 g.
List all applicable well contraction permits(Le UIC,County,State,Variance,etc.) Mi t • �2'
, Qt. to ' .��
3.Well Use(check well use): Mal
Water Supply Well: .__r.,f, la.,,,ia,44 7n, -!r,'Mil,Ii :..il.. 11/.vl:.It14.
■Agricultural •cipal/Publia ft. ft. In. ---
■Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R R IL ---
■ Industrial/Commercial DRasideatial Water Supply(shared) - -- = --
■I<ripztion ft. ft.
Non-Water Supply Well:
I Monitoring fRecovety ft. ft.
Injection Well: ft. R
R DGrouttawater Remediation
II Aquifer Storage and Recovery DSalmrty Barrier tifttEMIlliill r — \-Az,ni;C.:c,�1 a:t i 1 a v )♦
R Aquifer Test DStormwater Drainage ft. R
Subsidence Control tt ft.R Teclmology —_ _.-_ -- _
Ill Geothermal(Closed Loop) ITT •
Its �:; ���;:rt ^�€" '1,-. ; of
■Geothermal(HeatinWCooling Return) [Other(explain under#21 Remadcs) /� ' r� ,
Q- '/ (y R �a R '.a'. .Ire, / ,y
4.Date Wells)Completed: Well ID# WEI a e G ,,i
511.W Location: IffMil f t�1 `�, a
Nara)00 4 eai)ov' ft. ft. .
illIM
_J R.
F iptt R
rQ3 t 7 .��, �ll g /f/;t liwble) ft. it. 11111Millill
. , ft. ft.rhyg Address,c Inir�tis 7, '�.
City,and zap 0 p• a / "- - -
County Parcel Identification No.(PIN)
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Ewell field,one Iat/long is sufficient) I - /I 22. tion:
aI)'3II N 80 �- 0 i w 2�ivr 0-err'
r Signature of ed Well-Contractor Date
6.Is(are)the weil(a) remanent or Temporary
By signing this form.1 hereby ce tify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction information and explain the nature of the copy of this record has berm provided to the well ownen
ear snider#21 rea0ls section or on the back of thisform. 23.Site diagram or additional well details:
8.For Geoprobed PT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drifted: SUBMITLaL INSTRUCTIONS
/ k/
9.Total well depth below land surface: (ft-) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells hst all depths tfdifJerent(trample-3Q200'and 2®1001 construction to the following:
10.Static water level below top of easing: 436 I
(ft.) Division of Water Resources,information Processing Unit,
ranter level is above casing use'•+"e 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: m Cam) 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,etc.)
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 testi err 24c.For Water Snooty&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount: a ape , completion of well construction to the county health department of the county
where constructed.
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Form GW-I. North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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