GW1--03098_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: gll17111
1.Well Contractor Information:
Ricky Corriher - _ - — ---. .
Well Contractor Name TO DESCRIPTION
2464-A . TIL .2 ` /!
NC Well Contractor Certification Number (.
Frank A.Comher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
/ iL ft. m.
Company NUM ��� D --- _. ----- --- -------- - -_----- ------ - -
2.Well Construction Permit#: FROM To DIAMETER 7Tt,C1t1 lttA[MATERIAL
\ List all applicable well construction permits(t.a.UIC.County,Stacie,Variance,etc-) t'1 ft. / ft. 6 iB is
SDR-21 we
3.Well Use(check well use): ft- lalliW. S ''' D C//
`,, Water Supply Well: _
Agricultural
� FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
■ !,,•cipaUPublic ft. ft. in.
( Geothermal(Heating/Cooling Supply) t' ':.idential Water Supply(single) ft ft. in.
Industrial/Commercial DResiden ial Water Supply(shared) -.--. --
r Irrigation FROM- _.T17.- -----MATERIAL EMPLACEMENT METHOD&AMOUNT
s"----j, Non-Water Supply Well: ft. ft_
I�. Monitoring (�i ery ft.
v Injection Well:
ft ft.
CC
Aquifer Recharge ©Groundwater Remediation _-- :-
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft
Experimental Technology ()Subsidence Control R. ft.
Geothermal(Closed Loop) [Tracer
Geothermal(Heating/Coolingg Return) `Other(explain under#21 Remarks) FROM ft. - U ft TO DRl for Dior,rwra. ,eat.��t Er,I.ey.tl
4.Date Well(s)Completed:3'-I 0 `') (! well m# !1(? ft- `4 d ft.
S4�``��yF 1 PLC
ii Sa.Well Location: t2 ft. 73 tt S o�� JL f L
ll /I�l:l a IV t 1 sr 3 fsS`Tt b I u � -
vFacility/Owmr Name 1 Facility iD#(if applicable) ft. ft. .,
` 10q{C) 13,ici SAc-1 Lane s4144.,4,Z914‘ ft. MAY 2 4 2024
R tt
p �� Ate.�S^and T.iQ /,�f 8� _ -- - -
�\ County Parcel Identification No.(PIN) ._ -
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degree's:
(35,ll6 7 one 9 is t) so 3 7 7 22.0 �n
L • N w < i/r!J -01 1 3`J6 - 07
6.Ware)the weli(s) ent or [Temporary Signature of vs 4-,Well Contractor pate
By signing this form,/hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing wen: Dyes or Me with 1SA NCAC 02C.0100 or 15!SIGIC 02C.0200 Well Construction Standards and that a
If this is a rr-pay.; out known well construction information and explain the nature of the copy of this record has been provided to the wen mother
repair under#21 remarks section or on the back of this form
23.Site diagram or additional well details:
8.For PT or Closed-LoopYou may use the back of this page to provide additional well site details or well
Geoprobe/D Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled
�� SUBMITTAL INSTRUCTIONS
9.Total wellbelowland depth
la surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200•and 2(4100') construction to the following:
10.Static water level below top of casing: 30 (ft-) 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: (- (in.) 24b.For Iniectton 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.
2 Well construction construction to the following:
(i.e.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) 3 Method of test: Air 24c.For Water Sum*&Iniection Wells: In addition to temdi rg the form to
[� the address(es) above, also submit one copy of this form within 30 days of
St
13b.Disinfection type: � Amoun> % Ccy� 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 R. eed 2-22-2016