GW1--02472_Well Construction - GW1_20240423

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 111111117
1.Well Contractor Information:
Ricky Corriher -. ._._�__f- .- ___-42
i � urSCRlrnON
WellContramrName b f. ?3—ft*
IIMEIMMIIII
2464-A P, 0 e.4. R 3to qi/
NC Well Comex Certification Number •
Frank A.Corriher 8t Sons Well Drilling, Inc. — tip I')r•V, ",:era':""":"`-` - a
ft. ft. in.
Company Name _ a'f , : _
2.Well Construction Permit#: 4haJ.�� r1%1i 1 ~~ i�,� �t�: ��: ..• '�
List all applicable well construction permits(in UIC.County.State.Variance.etc) a� ft- 61B I, tn' SDR-21 rue
3.Well Use(checkwell use): 3 k-ft. Yp ft- « ir,
Water Supply Well: tfilk..._1' 11... .a.;"iillI ;i1�Ihis :ill
I . •,:cultural ©MunicipaliPublic ft ft. in.
I r_,........ (Htlingg/Cooling Supply) .OResidential Water Supply(single) Ic ft. in
T
--
Industrial/Commercial OResidffitial Water Supply(shared) _- -- _ - ; -" :,_;
.,l "'ircimi a,r,N or a rl ilillillE.„'.ws.a,;i'S,dui4r.'.T,tfu„(1.1r:ri
■ ikon ft it
Non-Water Supply Well:
I Monitoring ORecovery ft It
Injection Weil: ft. R
I , Recharge OGroundwater Remediation _ T
- -- -----I Acjitifer Storage and Recovery . DSalmlty Barrier FROM r.. ■1J i:5C..n ,:.11 VIA t.,•fll_
IliAquifer Test
IDStormvrater Drainage ft' ft.
■Experimental Technology OSnbsidr nr,.Control T ft. ft. •
III Geothermal Geothermal(Closed Loop) OTracer t C --:,1-0.: i i. • •. . -7
■Geothermal(I•IeahnF/Cooling Rehm) [iOfher(explain under#21 Remarks) V ft' INEfirr
n
4.Date Well(s)Completed: )`)6_9 y Well i ")e.) ft- d ft' SoninerARMIMIE
did ft. 1 e? d- ,4111 —/Z.
Sa..Well Locadon: ^0 L q n 3a) Jo tee—
FaeHity/Owner Name Facility MO(if applicable)
ft. ft.
ft. ft.
P7i3a1 Address.City,and Zip
..... --_ s -_--
County Parcel Identification No.(PIN) i
i. aP r f A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ✓y 1
80 am. .p �..: , ;; a , y
35. Cl/tic 1• 3 N e5 �� �L� w .� l
�7 Ci;P�./vl i ke.1 m r'1. i
6.Is(are)the wells ermsaent or [Temporary , Signature of Celtifi�Well Contractor Date V `
i By signing this form.I hereby car*that the wells)war(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out lotown well construction information and explain the nature of the cOPJ ofthu record has been prowded m the well owner.
repair under#21 remarks 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/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells e,onstruction details- You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS _
9.Total well depth below land surface: i C (fi-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formagpie wells list ail depths ifdifferent(example-3©20/0• 2 and �100') construction to the following: .
10.Static water level below top of casing: V 0 (ft) Division of Water Resources,Information Processing Unit,
If corder level is above casing use"+"i 1617 Mail Sery 4ce:Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in-) 24b.For Injection Wells: ht1
m 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.anger,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
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13a.Yield(gpm) Method of test:err 24c.For Water Snarly&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type: Stenlene Amount: completion of well construction to the county health department of the county
where constructed J
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water i races Revised 2-22-2016
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