GW1--00283_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contactor Name �� S DESCRIPTION '
2464-A -0 ft. NM ? CVAMIIIIIIIIIIIIIIII ft.
NC Well Contractor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. Ettliiii — I i i 'UNI"irs NO/,',
f'L ft. in.
Company Name
1.Well Construction Permit#: //r`l �9. a"? warimmiriMmui on,13 I s1111111111,,y r:I kill.11=9.1111111.11
_
List all applicable well construction permits(i.e.UIC ounty,State,Variance,etc.) = AME 61/8 in SDR 21 we
3.Well Use(check well use): ®'
IMILTIMIII
Water Supply Well: © ®®
v r r � r . �.�
Agricultural °Municipal/Public ft. ft
thermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. �__-
ustrial/Commercial DResidential Water Supply(shared) .a., =
\, Irrigations ft. . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery ft. ft.
3 Injection Well: ftft. Ell
Aquifer Recharge OGroundwater Rcmediation _
Aquifer Storage and Recovery 0 Salinity Barrier IIIMMitallill=1 S Az t •Cr1 A 1'',a 1 n r CC a
/ Aquifer Test 0Stormwater Drainage ft' ft
Experimental Technology °Subsidence Control ft_ ft.
Geothermal(Closed Loop) OTracer
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Cla'�r� , , n "xl �i "'"r-'w?al♦
o no � ��I
t I 4.Date Weli(s)Completed: Well ID# LI�7 ft
— 5a.Well Location: -I 7 ft. MA 6 ;a _ 6 _
(I) Sk y �aof ei/ f` ft.
Facility/Owner Name, Facility ID#(if licable) ft
ft ft
3 60- r a,? Rci Co/7t?�
ft. MMilantiffiral..
Physical A ,City,and Zip
C'of arrcuss luN
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) l 22.Ce ' rt: � - ✓rl rrn
35 0az l�0'1 N 80C3 /
/- ,, w _ �,,.✓"`' � °` `i _a
6.Is(are)the well s dy�/errmmanent or Temporary Signature o ell Contr t Date
Oiler
By signing this form,I hereby cent(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or It No with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known 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 diagram 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 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: 1 �� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: a Jam✓ (R-) 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: V (in.) 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS�j ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a�/ Method of test: Air 24c.For Water Saintly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilerte Amount: Q( 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