GW1--01831_Well Construction - GW1_20240322

•
Mr
WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Wen Contractor Information:
Ricky Corriher ••
:; ,..
-- _: _
FROM
1, ° r`�wellConnacrarName ccV t, f � /
2464-A P-7 Vt a-75-1. z C
NC Well Contactor Certification Nmaber - •-7-- .�-C
Frank A.Corriher&Sons Well Drilling,Inc. FROM TO DIAMETER' THICIME.sS MATERIAL -
ft. ft.
Cody Name �� / � T
2.Wen Coma-action Permit#: To DIAMETER rmaavEss MATERIAL
List all appli .hI. 10311 consbar�on permits(i.e.UIG Cotmty.State.Variance.etc.) °,, D' I, ft' 61B . In' SDR 21 eve
3.Well Use(check well use): ft. 6� ft. I? T' Yid
Water.Supply Well: FROM To DIAMETER starsIii . T[nCknvtss MATERUL
cultural unicipal/Public ft. ft. , in
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft, ft. in.,
Industrial/Commercial QRtsidential Water Supply(shared) ria A, .0 - ,_`- 'L.� st°_ _:: -
Irrigation FROM TO ME MATERIAL EMPLACEMENT MEiHOD&AMOUNT
ft
Non-Water Supply Well: ft.
• Monitoring — QRecovery - ft. tt -- _ - - -
Injection Well: ft. ft.
Aquifer Recharge ©Groundwater Remediatio;t ;
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMFLACEMENrAmnon
• Aquifer Test EiStoimwater Drainage ft. ft. I'
Experkpental Technology DSubsidence Control ft, ft -
•
Geothermal(Closed Loop) DTracer, WillninlatilligilMitil.f - i 1 -" .. 3 W-
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROMft. TO ° � t eke.)
4.Date Wells)Completed:3-// a Well ID# D ft. A/a F.,..,
m J
Sa Well Location: !D IL �`3 ft C k,
Facility/Owner Nam �de,' jeh,yc
Facii ity ID#(if applicable)15 ) 9r3a, 9,4tAry ft- ft. "T t=-s i 1
• R
Physical Address,City,and Zip
R© ti a 1? „Q®7,00 2 W_.VIV/111lrr 'NO 11 1 .r,..,,1 j--ikl = -‘IVO/
County Parcel Identification No.(PIN) 7�- ;;'z-�iii:$ -
ln;:ri;..31i..�;-1 . :7.:,r:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L'v+.✓1. �G
(if well field,one tat/long is sufficient) e� 22. Lion:
35e�✓ a `�� gi N 80, 6�� / (1 w ,, � i ' 3`"11�/-
6.Is(are)the well(s�ermanent or ]Temporary Si of Well Contractor I , Date
By signing this form,I hereby certify that the*elks)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Mlo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
-
!Phis is a reps fill out known well construction information and explain the nature of the cop aft record has been provided to the well owner.
repair under#2!remarks section or on the back ojdtis form. 23.Site diagram or additional well details:
&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-1 is needed. Indicate TOTAL NUMBER of wells construction details. Yon may also attach additional pages if necessary.
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IF5 (f) 24a.For All Weld: Submit this form within 30 days of completion of well
For multiple wells list all depths f d fferent(example-3@200'and 2®100') -construction to the following: I' '
I
10.Static water level below top of casing: S (it.) Division of Water Resources,Information Processing Unit,
If writer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fro) 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.anger,rotary,cable,direct push,etc.)
Division of Water Resonrces,,Undergronmd Injection Control Program, •::
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 0 Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
�j the address(es) above, also submit:one copy of this form within 30 days of
13h Disinfection type: Stemene Amount: rJ e r 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
•
,