GW1--07230_Well Construction - GW1_20231108

•.Am4a4 a..aerto 11cut.1ION KL!,CORD(GW--1) For Internal Use Only: i'
L Well Contractor Information: •
Ricky Corriher
WeIICoataetorldame FROM . .... -=-----=---..
2464-A �Jt �2 2 DESCRIPTIONe —
NC Well'C,o C Number �� ( �cl
Frank A. Corriher&SSons Well Drilling, Inc. FROM TO Dry
Coyle • ft. in.
/
2.wen gas<trin:linn Permit#: ao 23 3a li$ -7 b. npnt i iii a c ss --may
List al1 applrcrablewell constructionpermru(Le.arc County,State,Va iance,etc) +1 ft. �S, b ft 61/8 I m. SDR-21 PVC
3.Well Use(check well use): O�6 ft g-b ft i�/ ' /D l" k 0-a4-
Water Supply Weil: ll� '°
FROM TO DIAMETER SLOTSfZ6 Tom.. MATERIAL'
L .❑ ,„, I.. •,•hic . ft. ft. I,fn
OGeofhe mal(Reming/CoolingSupply) ,.r„'._.:. Water Supply(single)
Olndnstrial/C DResideffial Water Supply(shared)
:^-"—: - -.i M TO MATERIAL
TERIAL -'EMPLACEMENTMETROD ftAloterrtk Olrigaton DWels>100,000GPD
Non-WaterSupplyw�'
0_: R 22 R Bentonite Hole Plug
0Mortitoring ORecovery g: ft i,
Injection Well: •
OA4ffif$Rharpe •
OGfoimdwaterRemediation` `'_ - _°—_
f' _ `OAgni Storage and Recovery OSalmay Barrier :TO - M:ass.:- METROD I L`
DAgaier Test OSformwater Drainage ft. ft
0ExperMental Technology OSubsidrnae Control• fr ft
k‘.. N DG l(C1osedLoop) OTmcer _ --- _- --'
OCeotheaaal(lieating/CoolingRetam) " DOtber(esplain'uader#21 Remarks) FROMft_ TO type.ask
�.�1
4.Date Well(s) g Coa leted:�`dc —9/.3 wen m# ;d f Vft' iA 0 4-6,4) A t�/ /C
Vsa Well Location: rf`' Y E ' 4- G_. L,✓��
Un V 4Serpoo/ �J ft. f` ;, €; .t„_ . . :' `v-r `�. ,
` Facility/Owner Name Facility MO(if applicable)o //5 ft ft
N Name,/
%Sd� rq/yy'I�crrloo� �ld� f< ft �, N&V J a 20Z3
` 7.772:ei,,,..
. v., /�J i34
`7 ft ft €r.; .;;ti .r,,
Cowry. Patael Idmnificayon No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwelt field,one ladbag is n ese) 22. n:
35 co ' ..7„ N 80o`• yy r-3g of w 1l/n A^ ',(�,
6.Is(ate)the walks): di-moment aertnanent or•
S'F of Well_ ��Q`t `�L! , Date
9=47J
() OTemporary T I Dace
Bvsigning thisfonr4 Thereby ceb:[v;hat'the w-11)Has(were)constructed m accordance with
7.is this a repair In an existing well: OYes or o 154 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Caa ,Sander and that .
&this is a repair fill otd brown well construction informa:ices soul esplaii t the naha-e office ofthir recorl has been provided to the well owner. °repair under#21 Tamils section or on the back of this form.
- 23.Situ diagram or additional well detsl
info
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sameYou may use the back of this page to provide additional well on
only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add`See Ova'.in Remarks Boa).You may also attach additionaipages ifnec es�ny.
construction, 24-SUBMTITAL INSTRUCTIONS
9.Total well depth below land surface:
Far multiple wells ataidepda ifrFgaou(esansple-3(a)200'and 2QI001 ( ) Submit this GR+1 within 30 days of well co�letioa per tbefollowfng:
10.Static water level below top of casing: V�q r'(_) - For All Wells: Original foam to DiviQon of Water Resources (DWR),
&xaterlevtl is above erne"+^
i Information Processing iJIIit,1617 MSC,
Raleigh,NC 27699-1617
11.Borehole ;6" On-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC).
12.Well Air Drill Program,1636 MSC'Raleigh,NC 27699-1636
central on method: t ' .
(i anger,rotary,cable,fitter push,etc) 24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
county envitomnen at health department ofthe coimty where installed
FOR WATER SUPPLY WELLS ONLY:
g 1 24d.For Water Wells producing over 100,000 GPD:Copy to Dom,CCPCUA
�.Yield(SPA /a1 Method of test Al r Permit Program,1611 MSC,Raleigh,NC 27699-1611
I,
13b.Disinfection type:Sterilene Amount 45 e pS
Point cw-1 1
•
North Carolina Department oflavisoameatal Quality-Division of Water Resouttucs
Revised 6-6-2018
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