GW1--03931_Well Construction - GW1_20240705

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Ricky Corriher -.
Well Contractor Name FR� _To DESCRIPTION
2464-A 4'ar�"` ?a Sn S� Vie:/ --_I
ft. ft.
NC Well Cord actor Certification Number — —
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. in.
Company Name -- - - —
Lii2.Well Construction Permit# FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,Cowry,State.Variance.etc.) .I--) ft. ..1 y ft- 6 1l8 in. sort 2t we
3.Well Use(check well use): .1 Li ft. .2` ft- 6 S !} 'a /S C"- ill
WaterWell:
Supply FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
Agricultural D 'i.cipaUPublic ft, ft. in.
Geothermal(Heating/Cooling Supply) i"A Residential Water Supply(single) ft. ft. j in
Inds. ialfCotmnercial DRtsidential Water Supply(shared) Iput_v.v. .....m'j r'r 1'--- /III III it ,_11 is - 4_1 --44
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
'
Non-Water Supply Well: ft ft _
Monitoring ()Recovery ft. ft. 1
Injection Well: fL ft.
Aquifer Recharge DGroundwater Remediation -_ ----_-.- , _. -- ._--------____--
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft ft. —
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ?ROTA TO DESCRIPTION(Dire.Mrdaem sea/roct tyre teat;slag etc)
a.Date Well(s)Completed: s 2 7 Well IIS# 1 Sf -(e ft. /c.ek..2 re
Sa.Well Location: • 26 ft. 7 1 f-ti' 5 iLt. .1-- P ivt le C7y'44...
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r�'ty�/Owi Name Faeility1130(if )2N ft. ft - \�• `r : �� �;
Fec
823 8 �!%I o /�(/ ok )&19 , ;sAtA yNcor7(, ft.R ft.
,1}L 0 z 2074
Ph stii./.<Address,11/City,and Zip /;c Ll V V 7 ___ • ==
County O � Parcel Identification No.(PIN)
__. --- --_ — •
a,...,j`
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) //'� 22.Ce do
35 , (1 7L) V' i N 80,,4 I -
g W ///J _�
6.Is(are)the well(s) Pernnnent or Temporary S nature of ,fia!well Caattactor 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: °Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ftll out brown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diag:ani 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 necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -7 g ) (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well-list all depths if different(example-3®200'and 2®100') construction to the following:
I 10.Static water level below top of casing: 1. 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+"- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Lr.., (In.) 24b.For Injection Wells: In addition to sending the form to the address in"a
12 Well construction method: Air Drill above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le_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: Ate 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Stenlene Amount (. l_/tie] 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