GW1--03007_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 11111711111
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name 3�v ft. c�/
2464-A
t1. ft.
NC Well Contractor Certification Number - .. _
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name /`�'D ry� / ----- —
2.Well Construction Permit# OY VLM TO DIAMEI 3R TWC7QYEs5 MAtEttlAt
List all applicable well coaso Yction permits(i.e.UIC,County,State.Variance,etc.) 11 I u ft 1 q ft 6 r/B in. SDR-21 rs;�
3.Well Use(check well use): 77 ft 7 6 ft. in. ` . C - •
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agriculuifal O cipallPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, in.
Industrial/Commercial °Residential Water Supply(shared) ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft.
Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation _ ,_- _ -- . . -------— • --:.-
Aquifer Storage and Recovery DSaLnrty Barrier FROM TO MATERIAL _ EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage — ft' ft.
Experimental Technology ID SubsidenceControl IL ft.
Geothermal(Closed Loop) °Tracer
PROM (eater,
——
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) ft. . fr D ImoN r r.�•a.a.,..rek type,grails.� t
4.Date Well(s)Completed: ` I Z'"- / Well ID# y o ft 7a ft' 5(q- t /?♦a<
ft
Sa.Well Location: ?d L f/ R N •
���^ 't
a.;n 71f pecSiq s ft.
act-city/Owner Name Facility IDe(if applicable) ft' R '.?AY ? 0 20 L
g. go co lor /21 Sal f. 2FiQ4 _ ft. ft.
City,and Zip ft ft.
County Parcel Identification No.(PIN)
-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if
5 we' nis y �f 9 9 22.C don: /�/jai"...35 s7OC N 8O, R K/ /..?a
6.Is(are)the wells) ermanent or ()Temporary Signature of Certified well Contractor Date
By signing this form,1 hereby e,tify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well DYes or e
with ISA NCAC 02C.0l00 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this is a rep ..fill out brown well construction information and explain the nature of the copy of this record has been provided to the well owe.
repair wider#21 remarks section or on the back of this form. 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-1 is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional pages if nerrccary.
drilled: /► SUBMITTAL INSTRUCTIONS
�,(v
9.Total well depth below land surface: / c (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(f different(example-3Q200'and Qa2 100') construction to the following:
10.Static water level below top of casing: ' 5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+"6 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cn-) 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:
(Le.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
163E Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test Air 24c.For Water Supply&Injection 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: steril3ene Amount 7 C�S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016