GW1--01379_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher 4 •:, K,,
Well Contractor Name OM TO DESCRIPTION �, /
2464-A t gam ; G�'-f//
ft. ft.
NC Well Contractor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO 1 DIAMETER I THICKNESS MATERIAL
ft. ft iCompany Name ,,.J/ /L{� Pl J�c7' I m
Wirt
(i.e. TO DIAMETER .. THICKNESS MATERIAL
F
2.Well Construction Permit#:
List all applicable well construction permits WC,,County,State,Variance. �},
etc.) 1 7 p- /0 Y.ft• 61/8 in
� SDR-21 PVC3.Well Use(check well use): 0 . /06 ft. e 5, r r /$ yii
W
Water Supply Well: it -' s ..,.ems _*:-y 'e -c—�Y.1 rh . ;,t .-.m : .r;_`..,,,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
['Agricultural E 'cipaVPublic ft. ft. in.
[Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fr. fr. i.
glnduslziai/Commerciaj ['Residential Water Supply(shared) ;,L` `a- 3- VX , - ,: :, 4. � 1
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft I
• Monitoring pRecovery ft. ft.
- - Injection Well: . - ft ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• Aquifer Test D Stormwater Drainage ftft
['Experimental Technology 10 Subsidence Control ft ft
DGeothermal(Closed Loop) ['Tracer s= :Y
DGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) e ft TOke ft. . (co I s°'u'°`k type grain
4.Date Well(s)Completed: Er" Well ID# 6 a ft. �,0 ft. •
- 0
5a.Well Location:
ft ��,6ft �sp
Facility/ Name Facility ID#(if applicable) ft ft 'i i..d�,/ t
7/t 6. Pelee Z.cs02 e fl oa'e,Sv,Z' .2gf ft. ft. MAR A
Physical Addriccis, ity,and Zip f` ft. _ 2Q2
County Parcel Identification No.(PIN) I�VJQr3OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlon sufficient) 22.Ce lion: •
35-,63.E iv N 80. $9 7517.- W
6.Is(are)the well(s) ermanent or Temporary esrir,,,,x .2-,2?--. ,i
Signature of eititi well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes or No with 1SA 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 I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nexascary,
drilled: SUBMITTAL INSTRUCTIONS •
9.Total well depth below land surface: /t-5' (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For muhiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use''+"
1617 Mail Service Center,Raleigh,NC 27699-1617 `
11.Borehole diameter: & (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:
(ie.auger,rotary,cable,direct push,etc.) g
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 Supply&Injection Wells: In addition to sending the form to
Sterilene ,Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount '�"/ `�c completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I I Revised 2-22-2016
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