GW1--00998_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher ,, - _ a IIE ,-4s. I IE z
thi �'� DESCRIP'RON
Well Contractor Name r '�_ s/
2464-A �At
NC Well Contractor Certification Number • ry „. 7 ,--;r: 4 • r a\ a. . ,. 7:
Frank A.Corriher&Sons Well Drilling, Inc. ' ' 6,:icoN::yz
ft. ft. , in.
: onPet#.
mpany Name
� v 6 q 67 �wi.ae..?..._.c,;.«:.a,J.e x�„--� a �o°`,.�:.:.... ),� .G_. `s"�-�. a ".t. ��
;yd d9 1 ��.,1►3„,'ar'��ir::cy+,:���
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) aMI 61/J 661118���in* SDR-21 we
3.Well Use(check well use): PS= 06 ft'
Water SupplyWell: r t:e :. < ,inCtakinlgiti°_ - $x'u : - z 4-1�
aMINI
Agricultural © unicipal/Public ft. ft. in.3Geothemial(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. is
Industrial/Commercial OResidential Water Supply(shared) a V y „r
Irrigation �� � . Y it,
A„I�:r llvla r:1uflL„U1iJ.i
Non-Water Supply Well:
1ft' ft
Monitoring Recovery it- ft
Injection Well: ft, ft
Aquifer Recharge ®Groundwater Remediation
`' _e_�-? saa' ,.�.v.:1:��r�.>�:aP'fis.':`S.-t�. ,.a:.ur:
AquiferStorageandRecovery OSalinityBarrier �� ��Iau�wCMa„is:ri,tar;t���)♦
Aquifer Test OStormwater Drainage ft.
ft.
Experimental Technology Subsidence Control D
Geothermal(Closed Loop) Tracer t . - . :— ,,,,; ‘ - -. .W.& —
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) �� mi!x �t.r t!1 rt-i ?r m __ -___ _
irlil
4.Date Well(s)Completed: 1 L 1Well ID# 2�d�j��� i ft' !Z%..� % `' ����
5 fly llLocation: 'f Il iICI /'/, �� l %Y.►�'�lt/J�7'C7C
11 �/L/1,i C IIM
iC/ �" Z✓''l vl dikeeC4,04M5
ft ft
lloi
ft. ftERMII
�. .
Facility win.,Nape Raiil
er r-, i ID#(if applicable))
20 /<eM kat/r7 G4,;I C" ,.0 : •
Physical Address,City,and Zip - ,
/%tom'�!i/ / / a_r:er,,,,-„,7„....„:„..„.„,-,„,..„.„,,,,,,,,„ . .;._..... F__ , ,""_^'t c._Y,ri
049
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 1/ 22.Ce cation: �J
35Q�"3 J 'r� `� N 80 �' y% X /i,,a/�.../4 . ,"dt
6.Is(are)the well(s) rmanent or Temporary Signature of Cemed Well Contractor Date
By signing this form,I hereby certify that the we/1(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repo'.fillout known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 r em arkt section or on the back of this form.
____23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/I)PT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nsreccary,
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V`__ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3Q200'and 2@!00') construction to the following:
10.Static water level below top of casing: 3 ° (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"1-.e 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 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:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: __ 1636 Mail Service Center,Raleigh,NC 27699-1636 -
1
/� Air 24c.For Water Supply&Injection Wells: In addition to sendin the form to
13a.Yield(gpm) �✓ Method of test: g
,� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount t� G completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016