GW1--01034_Well Construction - GW1_20240212

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WELL CONSTRUCTION RECORD(GW:l) For Internal Use Only: 1 71111111
1.Well Contactor Information: ' '
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Ricky Comher -_ ._. - F-- _.— -
_s.--_._.__Y —n
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FROM �TO DESCRIP[LON
Well Contractor Name 7 0 R f 049ft. Gt/J • -
2464-A ft. ft. I I
NC Well Contractor Certification Number •
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO , DIAMETER 'TRICHNESS MATERIAL
2.Well Construction Permit If: _T� `DIAMETER rmcxi ss MnnTatrm,
. List all applicable well construction permits(i.e.(TIC,County.State,variance,etc) ft. l iD R 61B li ! in- SDR 221 we 3.Weil Use(check well use): 0 ft' ,,,3 ft' afr`•' jD 9 `L 0 _. .
Water Supply Well: PROM To DIAMETER SLorslzE THICKNESS ,nverii 1.
Agricultural 'cipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) R R in-
' ladustrial/Commercial DResidential Water Supply(shared) _-- - _s 2..- ' -- •.,I,t=
FROM TO MATERIAL ThWeecesi NT METHOD&AMOUNT`
Irrigation R R
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well: ft. R
gee °Groundwater Remediation
Aquifer Storage and Recovery DSalmity Barrier 'FROM TO MATERIAL E tPI.Aacis-liter—min-HOD
Aquifer Test
OStormw Dra
inage ainage ft. ft.
Experimental Technology °Subsidence Control R R
Geothermal(Closed Loop) DTI FROM TO D oN(eofar, soohodc true,gran eta, ) _v
Geothermal(I1eating/Cooling Return) .['Other(explain under#21 Remarks) © R /'0 R / d(.J/a :/'
4.Date We➢(s)Completed:a r-1.-a / Well ID# / ) ft `/3 R 3^/ "ciao.J._ )) � n
52.Wen lion• 2 y3 R /G-f R I /ke 4 41 Lde-Grbv -
( o.-f74'f/ Thp14,odis-i-chwr&h - f` G .ft. -.I, '
Facility/ Facility Mit(if applrcable) Z// - ..,,.. :._h i_ \.r j..,i vt 3 r
ri o :73o 61-C-phhc e/ir,(, Pd /d/i/,1) R R
ft. . R - E6i22014
City,and Zip
Couaty • Parcel Identification No.(PIN) `"mow w,i0C
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
( well
➢mod.one is...sufficient)
3 a -7 6 22. lion:
1% N 80 W
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• Sigaatiae of Certifi Well Conuacton Date
6.Is(are)the well(' Permanent or Tempo
By signing this form.I hereby oeriifylt/mt the wells}runs(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or o with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.fill out brawn well construction information and espial!:the nature of the COPY ofthas record has been provzded to the well closer.
-repair Ceder#21 remarks section or on the back of this form. ----- -. 23.Site diagram or additional well details:
8.For Geoptobe/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,ally 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled .� SUBMITTAL INSTRUCTIONS
�� (R-) 24a. For An Wells: Submit this form within 30 day 1.
s Total well depth below land surface: of completion of well '
For ntzltiple wells list all depths tfdiijfereni(example-3@200'and 2@l00') construction to the following: •
10.Static water level below top of casing: (✓ ( ) Division of Water Resources,Information Processing Unit,
Iftr�level is above casing,use"+' 1617 Mail Sery ice Center,Raleigh,NC 27699-1617
11.Borehole diameter: (7 Cm-) 24b.For iniection Welts: hi 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.Wen constriction method: construction to the following:j .
'(ie.anger,rotary,cable,direct push,etc.) I• •
Division of Water Resource§,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: -. -1636 Mail Service Center,.Raleigh,NC 27699-1636 •
13a.Yield(gpm) O Method of test:Air 24c.For Water Slimily&Injection Wells: In addition to sending the form to
n the address(es) above, also 'submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount d CR/' completion of well construction to-the county health department of the county
where conshucted.
Form GW-i - North Carolina Department of Environmental Quality-Division of Water Resou ces Revised 2-22-2016
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