GW1--01437_Well Construction - GW1_20240301

. 1 . 1.111.17
WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
1.Well Contractor Information: ,
Ricky Corriher _- _ _ -..:. a z a _-'_-__-._ _ _. _
FROM TO DesCRHTION
Well Contractor Name /ffo.01 D `,(
2464-A p e(Lxt' aZ )n, ,s''iv -
NC Well Contractor Certification Number _ O ,.- '.'if-
'
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO , DIAMETER N _TRICICNESS MATERIAL
ft. , I in.
Company Name nn q .: ,-
'J, FROM~ .T_.._ DIAMETER ThICKNESS MATERIAL
2.Well Construction Permit#: ✓✓
List all applicable Ken construction permits(Le.UIC,County,State.Variance,etc) �" ft• 7 2. R' 6118 !r in• SDR 21 we
3.Well Use(check well user
e�n F7 R' �o l't/Pm. 5''V Q l iJ
Water Supply Well: FROM..� -To DIAMETER Slats1Ze THltacn6U MATERIAL
Agri cutetual •cipal/Public ft. ft. hi.
Geothermal(Heating/Cooling Supply) ideutial Water Supply(single) ft. ft. rn. --..-
Industrial/Commercial E3Restdential Water Supply(shared) i ._ _ -_' :._.='► 1@! y .::= _i
FROM TO MATERIAL EMPLACEMENT METHOD a AMODNr • -
Irrigation ft. ft. I
Non-Water Supply Well: !
Monitoring DRecovery IL ft.
Injection Well: ft. ft.
Recharge DCmoundwater Remediation
Storage and Recovery DSal pity Barrier FROM To MATo tAL EMPIACEMENF MEIHOI/
Y DStormwater Drainage ft ft.
V,` Aquifer Test
t Experimental Technology DSubsidence Control It. ft.
Geothermal(Closed Loop) QT RROM /�Io Dray'?tco sdv�oce tma ail,etc.)
(Heating/Cooling Return) [Other(explain under#21 Remarks) V ft.
Z�' ft.
:'
9-6--at1 `iiv ft.40 ft- 5 ,illy P'r
4.Date Weil(s)Completed: Well ID#
5a.Well Location: _ 6") ft- ` 9 it �C ry
r,r'i.. \n/CL10,e6 R�ep'l0 zgi` 4�i e .79 ft. 1-b "R ( 14,____i_ wA: j.-G"
Facility/Owner Name
C ID#(if applicable) /4 It. ft. _
aO© 4✓' 114( ' it44-y ,o >}_i '
Phys' Address.City,4Sd ZiP _ ft I' `- _
/f5 / 6
Parcel Identification No.(PIN) ,'^ ""1 ° r•"`•
County l X L: Y
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: `i �
(if well Reid,cmInt/longissufficient) 22.Ce' • n: , e MAR J 1 20Z4
35• 7 [04 y N 80 ,.50 g-Ti ; w 0
i*t orzrawc7 ?rn*ir;.r;,;-UM
S of Cintifiegiell Connecter 1
6.Ware)the well(s)l ermanent or CiT'emporary i I
Q / By signing this for%I hereby certify that the Kell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out known well construction infonrtaaioa and explain the nature of the copy of this record has been provided to the well owner.
repair raider#21 rrmartr section or on the back of this form. - 23-Site diagram or additional well details:
&For GeoprobeIDPT 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is Indicate TOTAL NUMBER.of wells
' drilled: g_ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D-) 24a. For All Wells: Submit this form within 30 days of completion of well
' For multiple wells list ail depths tfdifjerent((trample-302 0 and
2 100') construction to the following: ,
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!flutter level is above casin&use••+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
i! 'i
11.Borehole diameter: (in.) 24b.For lniection 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.) T'
•
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,.Raleigh,NC 27699-1636 -
13a.Yield(gpm) I-0 Method of test:Air 24c.For Water Sunray&i I�section 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:'/ �-S completion of well construction to the county health department of the county
where constructed. I ,
Form GW-I, North Carolina Department of Environmental Quality-Division of Water Resou es Revised 2-22-2016
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