GW1--01790_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only- -
1.Well Contractor Information: ,
Ricky Corriher-• , • � t u�_ -
WellContractorName ,grara�—nsrne�ro2 r -=
2464-A ft. R
NC Well Contractor Certifiratidn Number •
Frank A.Corriher&Sons Well Drilling, Inc. • ii=umicimum iv F.V,1 lrslIMI�I;,Co,•IX
R • R i in.
Company Name
2.Well Construction Permit It: L .( (✓ 1 , ! ,,,.y. 7i r: M.•,i i- _
List all applicable well cOnstrnction pennits(Le.UIC County,State.Variance,etc) 11/11211 mac+ SDR-21 we -
3.Well Use(check well use): ft dr ft g =Nig
Watericuleral Supply Well: �`+`ft. ft. : r ,r i star sr� ;i t==
III �,. cipal/Publicin.,
Geothermal(Heating/Cooling Supply) 3 Residential Water Supply(single) R ft. in:
_—
Industrial/Commercial DResidential Water Supply(shared) ---- _ i. .
Irrigation • 'Q�. ` ■:,,J,i ir;ui,srel lira. Z-.,Wiry d
Non-Water Supply Well: R. ft.
Monitoring °Recovery ft. ft.
Injection Well: - _-- - .
Aquifer Recharge . °Groundwater Remediation - — —
Aquifer Storage and Recovery Salinity Barrier '•'+ E�- •
1 DAve 1 WLw.+,i:,;r ei far U)t)_
• Aquifer Test °Stormwater Drainage ft ft.
Experitaental Technology °Subsidence Control ft. ft. •
Geothermal(Closed Loop) °Tracer
Geothermal(HeatinglCooling Reetturn Other(explain under#21 Remarks) milrr
4.Date Well(s)Completed:3 Well ID# E2513
Sa.Wii°Location: 1 )— Q
Sir ot,elti�/ed"Ave,- f' 'i,Jchi$ i Milani 8 bi--e- .1--- ?Itf f( C� rr '
Facility//Owwner /7�s f��/ F Me(iifapplieabV 3 ft' ft. ,
ca/ Rae 1AA pbae. ..
/%County Parcel Identification No.(PIN) milliallminim r l i 1
decimal
5b.Latitude and longitude in degrees/minutes/seconds or degrees: I
7
(if welt field,one hat/long P p N 80 5.1‘
W 22.Cer '`n: Itliv,rfn^r''4 Pr:-r
35 +�r oq (6J tM :.^,:;: iii•I..
• 6.Is(are)the well ermanent or °Temporary Signature of ell t�/Coniracto Date
s
By signing this form,I hereby certify that d e wells)was(were)constructed in accordance
i. O with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a T.is this a repair to an existing well: °Yes or
Ifthis is a repay,fell out brown well construction informanon and explain the nature of the .copy ofthis record has been provided to the well owner.
repair wider#21 remarks section or on the back of thisforr_-
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 1 GW 11 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary-
' Wiled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / C6) ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For nwhipl.wells list all depths ifd different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: gc
(ft.) Division of Water Resources,
if water level is above caster roe"+" - Information Processing Unit,
1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: : Cam) 24b.For Infection 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
13a.Yield(gpm) /ca Method of test:Air 24c.For Water Supply&Iriiection Wells: In addition to send
ing the form to
Sterdtle the address(es) above, also submit one copy of this form within 30.days of
13b.Dion type: Amount completion of well construction;to the county health department of the county
where constructed- .
Fan GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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