GW1--03930_Well Construction - GW1_20240705

;Witt
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION...
Well Contractor Name Z�t- .{ "f't• /5 G
2464-A 7 v) 7 2 - c/
NC Well Contractor Certification Number
s:, .
Frank A. Comher&Sons Well Dulling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name - - -
ii i 0 y-, ,
2.Well Construction Permit#: FROMi TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) I ft- �y ft' 6 118 in SDR-21 PVC
3.Well Use(check well use): y ft .4 ft- (S'l}---in- / $-f e ((/
Water Supply Well:
FROM TO DIAMETER SLOT BITE TRIMNESS MATERIAL
Agricultural O icrpal/Public ft.
ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft• it. in.
Industrial/CommercialOResidential Water Supply(shared) �---
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD R AMOUNT
Non-Water Supply Well: it ft.
aMonitoring ORecovery ft ft,
Injection Well: 1
Aquifer Recharge OGroundwater Remeoiation
°Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer -�.r rr7 '.: `" '`,ux t1-1 sue'. ' "` "..`
Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,6ardeesa,soil frock type,gram size,etc)
°Geothermal(Heating/Coolin
iReturn) ['J it. .C/ ft. A-F'c . n)----
4.Date Well(s)Completed: 3 ' Well ID# it ft- ( ft. �(i-e__ C�,rsrt
Sa. ell Location: LL 2- ft_ 7'r �)Gt`�- l.��_ .i
19 C 1f(-e a n C'C'✓OS r le-f r,7/7 L LG ft. ft
• `�`��; 1T�
Facility/Owner Name Facility 1D#(if applicable)2O
2 h 1�ufn Lrci„k R Sc6l�cbtlt-y
ft. ft.11, �U� 0 2024
Physical Address,City,and Zip ft. ft. ll-.it5:SSi.4t'rl ?-r^dM'+r
ff o 5"6✓s03 b'' ,.. .
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certi lion:
80 / ,__.e,,____,a,__
6.Is(are)the well(s)errmanent or Temporary
Signature of Cert W ell ontraTTor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well Oyes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remar+s 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 5 (fL) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(4)I001 construction to the following:
f'; r
10.Static water level below top of casing: '' (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"E 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 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.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) 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: Sterilerte Amount: (2 C al S departmentcompletion of well construction to the county health of the county
/ where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016