GW1--03933_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-1) For Internal Use may: INTO
1.Well Contractor Information
Ricky Corliher
TO
Wen Co ctor Name V S' - y 7 ft. °5 5 ci
2464-A ft. / ft.'
NC wen Contractor Cc ation Number
Frank A.Corriher&Sons Weil Drifting, Inc. FROM TD DIAL THICKNESS MATERIAL
R ft. M.
Cody Name - -- _.— -- - -
i 1 a `7 1 C . TO DIAMETER .ow w MATERIAL
2.wen Cow Pest n nt
List all applicable webl eavtw•r�on permit. tie UIC.Cow'.Sane,f'ariance,etc.) H. ft s vB ka' SOR-21/ we
3.Wen Use(check well use): , c) ft ', t r i
Water Supply Weil: FROM TO DIAMETER SLOT SF THICKNESS MATERIAL
■M ,-cipal/Public ft ft. is
Geothermal(lleahug/Cooling Supply) It t' -..- Water Supply(single) it. ft. is.
�Rrsideutial Water Supply(shared) -_--
FRnIIt TO MATERIAL D4M.A tr METHOD t AMOt7NT
Irrigation ft ft_
Non-Water Supply Well: ft. ft !
Monitoring ❑R�0`�
t Injeea We'+: ft ft
—
3��i ttm Gturmdwater Remedia _ - — _.�
DAquifer Storage and Recovery ()Salinity
Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Qstormwater Drainage ft' ft'
Agmfer Test Tedmology ft. a.Subsidence Control ---- —_ --__—._.
'3C tb.4mal(Closed Loop) OTC
FROM TO -- trrtr.urih�erk l}Fe tiaah Fire,ee 3
)Geo al(Heatiaig onhng Return) dottier(explain under#21 Re rrtadta) tJ it. a. ' ,. j 4.4
&Date Wears)Corpbded:4 v 1® -Q (en 1D# ,-Id 69 v a- /s e 1 �-/ ,,
sir wY8 Location: 6 0 R' '�r+`i R'. 4 hAe_ /L7---14-
a.
��jo,.i S 4(2P,A e L b m.r�'. 1.)b2 f� V s. ` ` L;it's V L V
`" clSa6,s6a� �'ft. ft. JUL o E 2024
�0 75 f"a �� ft.
Physical Althea.City,and Z.ip V I /
R
County Parcel Ideanfcation No.(PIN)
Sb.Latitude and longiMde in degree>sbmmutes/seconds or decimal degrees: •
(35'ell 7 7 -7 aoe lot/long)sufficient)N 813. 5-9 (..
6.Ware)Me wr�(s) er nt or OTemporary Signature of Well Co eoueor Date
L! By signing this form,I hereby certify that hie well()war( e)consbwcted in aoor�dawct
7.Is this a repair to an existing welt °Yes or o with iSA NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fll on known we construction information and explain the nature of the COPY of this record has been provided to the well owner.
repay wader 1121 remarks section or on the back ojtha jarm. 23.Site diagram or additional well details:
&For Geoprebe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pad:to provide additional well site details or well
o on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details_ You may also attach additional pages if rrrrrccary-
drilled_ SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface: / 6. (ft-) 24a.. For Al Wells: Submit this form within 30 days of completion of well
For multiple was lie all depths i'different(example-33gt�t�77700' 0 and construction uction to the following:
10.Static water level below top of casing: (9 (ft-) Division of Water Resources,Information Processing Unit,
If water leed is above ding.we`+"i 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: T.' Cm-) 24b.For Infection 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:
•
(ire auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(ggm) L U _ Method of test: Air 24c.For Water Supply&IniectIon Wens: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
i 136.Don type. Steriene Amount .'2 C(/22 completion of well construction to the county health department of the county
where constructed_
Farm GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016