GW1--03901_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. 111117110
1.Well Contractor Information:
Ricky Corriher . _ —_- —�
FROM TO DESCRIPTION
Well Contractor Name ,0
R ii' . , I; G"
2464-A v ft. R
NC Well Connector Cati fiction Ntnnber _
Frank A.Cor iher&Sons Well Drilling, Inc. mom TO DLAMrTFR THICKNESS MATERIAL
ft. ft. M.
Compaq,Nana
Z.Well Construction Permit#: 93 FROMTo OtAll�l7rit T7 MATTtBIAL
List all ap iirehln well cw es permits fie UIC.Comoety.State.V rianc'e.etc.) ft. 7 ft 6 leer ig" SOR-21 rtic
3.Weil Use(check well nee): �y ft. � 1i C S' U Water Supply Wen: ,/ FROM TO - --DIAMETER SLAT Big THICKNESS MATERIAL
■ •=.NI ,.1: 0 ,..cipal/Public ft. ft. na. -
■Geothermal(Heating/Cooling Supply) 1 i '--iriaihal Water Supply(single) R ft la.
R °Rtsiaential water supply(fired) -- --
FROM _TO MATERIAL EMPLACEMENT METHOD&AMOUNT
III �� R ft_
Non-Water Simply Well:
■Monitoring °Recovery ft. ft_ r" 1
Injection well ft. ft. --� t, :—\.s L. '/E.
iJ
• -•,, Recharge °Groundwater Remediation -- -—
■Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL
ft' ft.
II Aquifer Test QSNrmwater Drainage w+w. ,,4 . k
t Rxpe irnesNsl Tedmnology Subsidence Control ft. ft. If�1y:sM. x;
• (Closed Loop) DTracer .. t�Wig ir,
__FROM TO ._
• ■Geothermal(Heating/Cooling Reran) 010ther
(explain under#21 Renaults)its) rU a. ,�y/)� R ,01't� ! / Ir.
4.Date We9(s)Completed:C r/r�` 7 Well iD# J ft 2v R 5� L. —
ft. rY R `7gte�• 1
Sn.Well Location: ?"
C i'feerna,n 6'a 5't"ru.C-71i94 J L C) )J� s-c,ft. Ll R _•, NL4, rC/j ., -
Nme Y Cd+PP e)2 1 ,, LL R
LG-�1 -440rc6s67 A7o,/3Yn
Zip -
County Parcel We:Mincaioa No.(PD) 1
5b.lAtidde and longitude In degrees/minut)es/seconds org 7 r decimal dI ne: a n , — -------
(tiw.6 sma, lst/iaag is s,«�..:.,.., .. oC / / / W ' �� T.
63g � ��N �, , )// �� C- ram- y
6.I,(arc)the wells etafaent or TemQerary Signature of Cali iced Well Co cif Dace
/ By signing this form,I hereby certify that the weU(s)wan(were)cavkstneeted in accord.,.',
7.Is this a repair to an existing well: °Yes or No war*1 SA NCAC 02C.0100 or 15A NC(C 02C.0200 Well Construction Stmtdonis and that a
If this is a repair...till oru known well construction information and explain the native of the copy of this record has been provided nee the well owner
repair under 1t21 rentals section or on the back of this form. 23.Sits diagram or additional will details:
S.For GeeprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
boa,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells won details. You may also attach additional pages if ttececcary.
drilled SUBMITTAL.INSTRUCTIONS
1
9.Total well depth below land surface: / J (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For maniple wells list all depths if different(example-304200'and 2®100') construction to the following:
10.Static water level below top of casing: �- 0 (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level v above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (.-' Cm-) 24h.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.e.an ,rotary,cable,direct pry,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY/WEI.1 S ONLY: 1636 Mad Service Center,Raleigh,NC 27699 1636
13a Yield(gpm) V Method of t, Air 24c.For Water Supply&Infection Wells: In addition to seeming the form to
the address(es) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: sterieneAmount C J completion of well construction to the county health department of the county
where consstrocted_
Form GW-I North Carolina D,p..tu...nt of Environmental Quality-Division of Wets Resources Re4..z12-22-2016