GW1--00782_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
i
I
Ricky Corriher 14.WATER-zoNEs <.
FROM TO DESCRIPTION �- -
Well Contractor Name
2464-A 6$ rt 940 ft: 02 cr. /
ft. ft.
NC Well Contractor Certification Number • 15.OUTER CASING(for multi-cased wells)OR LINER(if up licabie)
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. .
Company Name3V 7.73- 16.INNER'CASING OR TUBING(geothermal,closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4 ' ft. .5-7 ft• 6 1/8 in' SDR-21 PVC
3.Well Use(check well use): 1. ft. L n. A (/.�qAti
Water Supply Well: 17.SCREEN . ... � _.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
111 Agricultural 0 unicipal/Public ft. ft. in.
01 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.' ft. u in.
IF Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT "'
I I lrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
(Monitoring 0Recovery ft. ft. .
- _injection Well: ft. ft.
-
ji FAquifer Recharge LIGroundwater Rcmediation Iq SAND/GRAVEL PACK(if applicable)
IIIII Storage and Recovery E3 Salinity Barrier FROM TO- MATERIAL EMPLACEMENT METHOD
NI Aquifer Test 0 Stormwater Drainage ft ft.
mg Experimental Technology 0 Subsidence Control ft. ft.
"S" IGeothermal(Closed Loop) [)Tracer 20.DRILLING LOG(attach additional sheets if necessary) ^ = . .
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRI o(color,hardness,soilfrock type,grain size,etc.)
`� It. ��^I ft. if?..... 0 i j^�
4.Date Well(s)Completed: v �7- , _ Well ID# J.-i(] ft. ]V ft. C 0 f �
5a.Well Location: S"0 ft. �t� ft. v �� �;
-� • PI-e;2v.sk o' fr5ker 5--9 ft. 1� 1 Clll � . .
ft. ft.
�{� Facility/Owner Name r Facility
..)D#(if plicable) l
•
S YO 3 01 et/car-, x-Gl+ ockhiell ft. ft.
ft. ft.
C---). Physical Address,City,and Zip y/` v, 35ll/y�
g(O 21.REMARKS.-'. ' n y,
County Parcel Identification No.(PIN) "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �Ar) 3 1 264d
(if well field,one lat/long is sufficient) 22.Certif ation:
35033 N 80 0 ` /S-'._ I 0 W' l✓/7 Q/� � G;�,r;,:y:D L C:,./VV"-•7 5
6.Is(are)the well(s) ermanent or Temporary Signature of Certfiied Well Contractor Date
/ By signing this form,1 hereby certf&that the well(,)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or DC-
O with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formation 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 Youmay use the back of this page to provide additional well site details or well
construction,only 1 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: / _.c (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following: I •
0 I I
10.Static water level below top of casing: (ft.) 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: t7 (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.auger,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
13a.Yield(gpm) q,f✓ Method of test: Air 24c.For Water Supply&Iniection 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: Sterilene Amount 't Cc --C completion of well construction Ito 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