GW1--04555_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Ricky Corriher
Well Convector Name FROM TO DESCRIPTION
246E-A /PO ft- l2C-3t- 2!� 3 �/
ft. R
NC Well Contractor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER TRICICNESS MATERIAL
ft. ft. m.
Company Name - _.. .
2.well Construction Permit#: 4639.- g8 PROM TO DIAMI{TF:R THICKNESSlt+wrexi►L
List all applicable well construction permits lie.U/C,County.Stan.Variance,etc.) +"t` ( ft' Y� ft- 6 tB m' SDR-21 we
•
3.Well Use(check well use):
$ /7 ft. ) s''`m sf� f3 q CU
Water Supply Well: FROUI To DIAMETER SLOT&a THIOET4ESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft, In
Industrial/Commercial OResidential Water Supply(shared)
�on FROM TO u EMPLACEMENT METHOD&AMOUNT
IrriNon-Water Supply Well: ft' ft
Monitoring ORecovery ft- ft. i
Injection Well: ft. ft
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) PROM — TO UI ttC/C-c' aoWseea t7lr�.Della tt�tun)
4.Date Well(s)Completed: 7 / / well 11)# ft- ` 7 ft. So`Li.. ,1 ,
A C�5a.well Location: �� ft �- e
NiCo1�- Oil ldd►n ft. _ .
F /Owner Name Facility ID#(if applicable) ft R. r— -. :
fL ft
Physical Address,City,and Zip ft ft U L 3 ' [u Z 4
rya �, � ` , __-- - .._ - ... , `..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.CertificaNn:
35.� 9y7 � c N 80. i l L/ R 7/ / f/ �ij.�. 1 - 9 ��
6.Is(are)the wells) rmanent or OTem porary Si o Well Contractor 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 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repmr.fill 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 hark of this form.
23.Site diagram or additional well details:
8.For GeoprobefDPT or Closed-Loop Geothermal We.ILs having the same You may use the back of this page to provide additional well site details or well
construction,only I 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: / '5 (a-) 24a. For All Wells: Submit this form within 30 days of completion of weli
For multiple wells list all depths f different(example-3@200''and 2@i00') construction to the following:
level J
10.Static water below top of casing: / `, (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mali Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C• (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.anger,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
it
132 Yield(gpm) �C Method of test:Air 24c. For Water Simply&Injection Wells: In addition to spouting the form to
Stenlene
C Ge C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount , J completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolma Di,w,truer of Environmental Quality-Division of Water Resources Revised 2-22-2016