GW1--00995_Well Construction - GW1_20240208

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher Ss:: _k_ .r '.. ti. ,dt :. , •vfl c, -v
Well Coratac[orNamis FROM TO r DESCRIPTION
2464-A .��s� �`�s � 3�
ft. ft.
NC Well Contractor Certification Number ,t:s .x«:t ,i .;: , ),.: , c.'i $
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft I in.
Company Name �7 �f {
/ �J /�/
�DV � / V l:a,> "t.:.:_ �"...�3z •`..F.F:., .I 'M �, .,.:�.1'�w-,i�o,...�N��..�4���°�,"�•':'a
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) Q "'
/C
�ftt. `j y 61t8 ,I,n,' SDR-21 we
3.Well Use(check well use): d / /a# ft' ,t7 S(5 - ) cil t/
1- n:d:,' .'Pi''e<• ':,::.:. a?"., n r.-',., ? .4-4_-'�.4 4:•1 t e'3,""4 ':
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i , icipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) E''-idential Water Supply(single) ft g, is
Industrial/Commercial DResidential Water Supply(shared) r -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fr
Monitoring ['Recovery ft. ft.
Injection Well: g, ft,
Aquifer Recharge OGratmdwater Remediation ?. -.; . ,,t -49 R4 4 _ '. e -
Aquifer Storage and Recovery rjSalinity Barrier - FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft' ft'
Experimental Technology ()Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer , •:r a, . .s- ; si=•
FROM TO DFSCRI
Geothermal(Heating/CoolingReturn) [Other(explain under#21 Remarks) fo (eobr,hardness,sauroelc type grain size, )
4.Date Well(s)Completed: 9
`P/ Well IB# 7ft. �q 0N�
5a.Well Location: ` d ft. `a� ft 3'D,� /� -
e m� e sc,/t°S 1°1 ft- Yvrf- A) tjge G,�aw&-
FadilityIOwner!ane Facility ID#(if applicable) ftX , ''^'--
195 Ali-fro Al i oafes�i'e b..r
f, FEB U 8 2024
Physical Address,City,and Zip
• 4tniate i i'yr ,g uft
County Parcel Identification No.(PIN) DLVC;30.2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certi cation:
3503q 'L 7 t i N 800'�g1"— a3 e
6.Is(are)the well(s) . Permanent or Temporary
ll Contraco� :LA 1—tig'" g Y
Signature o ettit>�We Date
By signing this form,I hereby certify that the xell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or eNo with 15A 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 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: 9t//► ( ) 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: 3-5 (ft.) Division of Water Resources,Information Processing Unit,
((water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ✓ (in.) 24b.For Inflection 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: 1
(ie.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Air 24c.For Water Sunolv&Inflection 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 4 (oz"....0 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