GW1--06421_Well Construction - GW1_20241025

. ` IP[Itll Form;"
WELL CONSTRUCTION RECORD'(GW-1) For Internal Use Only: • •
1.Well Contractor Information:
Ricky Corriher •s14::wA'rER'ZONEs . ..w , s .;,,,,,.!•;,,,,-,
Well Contractor Name FROM TO DESCRIPTION
2464-A 5) ft. • 7,2 ft- 3. 1 .l
( ft fL 0 a ,/
NC Well Contractor Certification Number • „75s.OUTER;CA517!l r inultf-leas d jvelLs):OR LINER"(if a" lleable)5..` "_'
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER ' THICKNESS MATERIAL
ft. .ft. I'in.
Company Name �'"^
/ '-) • °FR I1VNER`CASIIVG'ORTUBIAM(Te"titttertnal.cl l ";
2.Well Construction Permit#: j' �J FROM TO DIAMETER THICKNESS MATERIAL
• List all applicable ive!l construction permits(Le. IC,County,State,Variance,etc.) i 3�/ rt. `� ft. 61/8 in* SDR-21 PVC
3.Well Use(check well use): % ft. vy'2 ft. in. / /�
�[7 am' v
27'SCREEN . ':E k - :', t z .i 4 es
Water Supply Well: FROM TO DIAMETER R st.o.0 SIZE THICKNESS MATERIAL
Agricultural Q if icipal/Public ' ft. •ft. in.
IDGeothermal(Heating/Cooling Supply) 11 Residential Water Supply(single)- ft. ft, in.
,
•Industrial/Conunercial - Residential Water Supply(shared) 18cGROUT. ).K,' „ ,i ...;,;),. ;r,,,F +'. a r < r 77.,:
©I Irrigation FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. 1
Monitoring QRecovery • ft. ft.
Injection Well: ft. ft: ' ' .
Aquifer Recharge - ' , 0Groundwater Remediation
'::79.SANDIGRAYEL:EACIC if-a'licable .'.
Aquifer'Storage and Recovery QSahnity Barrier' FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stolmwater Drainage fL ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer '20/%DRILLING=LOG°(attach•addltional'sheets if;hecessery) ::-."..:‘-.7"-',-:-.
FROM TO DES PTION(color,hardne s.soil/rock hype,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ® rt aO ft. eCII ,fj�'
4.Date Well(s)Completed: /9 //"Well ID# = acy ft. "3 ft• : . 4„:„..it
�� ft. ? R. S .1 GG
5a. 11 Location: _J 1
.. .. 7J ft.. rt.-
Facility/Owner Name .V Facility ID#(if applicable r ft- ft. t_ _ _ _
V1a5 K:,n o I (Or 044 /� , .
Physical Address,City,and Zip • ft. ft. I r
1 9 ` /
re ha 4 • / a �.1 a1:rRErornRxs _ n .,_.- , • ... _ 4 .-
County Parcel Identification No.(PIN) :� r'Z?-,•, 't„k
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iat/long is unfficicnt) D a 22.Certi lion• I C
35s • (PoL /N Sao 6D 4 7 / / w .
6.Is(are)the well(s) ermanent or Temporary Sign ofCcrti Vel CI" ontractor Date '7 9 e-g7
By signing this form,I hereby ccrtif}'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IJYes or t o • with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fit/out known well construction information and explain the n rtirre oldie - copy of this record-has been provided to the well owner.-
-
repair under#21 remarks section or on the back cif this form.
i 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the,back of this page nto provide additional well site details or well
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (O-�J (ft-) 24a. For All Wells: Submit this jiform within 30 days of completion of well
For multiple wells list all depths ifdi,greni(example-3@200 and 2QI00') • i construction to the following: i.
10.Static water level below top of casing: ry- O (ft.) .- Division of Water Resources,Information Processing Unit,
I(water level is above casing,use"a - 1617,Mail Service Center,Raleigh,NC 27699-1617
H.Borehole diameter: CO - (in.)--. .
24b.For Injection Wells:._In,addi ton to sending thc_forttt 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.- • -- • --- - -
(i.e:auger,rotary,cable;direct-push•etc.) • -- -. .- __- - I 1
• Division of Water Resources,Undergroutid Injcetion Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
[�
13a.Yield(gpm) - OE Air
- Method of test: - 24c. For Water Supply&Iniectionl Wells: In addition to sending the form to
Sterilene Q•/
the address(es)-above, also submit tine'copy of this form within 30 days of
13b.Disinfection type: Amount:(aa completion of well construction t d 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