GW1--01438_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: "
1.Well Contractor Information:
Ricky Corriher :i[^tlta'1:EIR;►A .."; ' t " ��rnx- .
1 t% t 1 DESCRIPTI�
oti
Well Contractor Name oc��ft. J/
2464-A t ft. ft.
NC Well Contractor Certification Number • MOrrigKatilgek(denl<it'u-liRi selll;s.(l1 r,A; `l ,, ;x
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name Li 0 (' 7 7 44 it�II!1Fl Sulhti".r'OATI11101 .,,.r n. -.et
2.Well Construction Permit#: FROM TO DIAMETER _THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County.State,Variance,etc.) 1 ft. r..y ft.
/61/B In
SDR-21 i PVC
3.Well Use(check well use): V ft $ ft h /�m 1a ��
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 111 t •icipaL/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft. ft. in,
Industrial/Commercial OResidential Water Supply(shared) -e- s •pwa e t- -x�, =zv g
A. ,
ti.,GR�3�r't�"s� .�xr. _+�..'a .a,§�.r,F�:. ,.,._�:.,.:-, c,d..h=.3..�. � .:.-.,� �a;<.�� �.:
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring Recovery ft. ft.
injection Well: - ' ft. ft. -
Aquifer Recharge 0 Groundwater Remediation
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft. .
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer zc26..=3 e{ski*':,:ddItte" .t:Ls`et iE `?`f "y A_,,tgAW',
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) FROM TO DEsc trrtoNpc°tn6aran wiVmck typa•cratn st7r eta)
ft Li 6)ft. e_ p I.. .-
4.Date Well(s)Completed:c d-5 cq Well ID# '/�°ft. 4 0 ft- $city J�
5a.Well Location: f9 d ft � ft. S r.�1 ,J
.3 `e v--er!� �9'dV ff' ;`eft- j) 4- �'IvdL cw,�-e,
Facility/Owner Name Facility #.(ifapplicable)„4O//3 ft. ft.
f e'-.2g°46/9 `)' diiI 1•C/ Z t ynca,si,'1(e ft. ft. ��C ; = V;� .;.
Phys 1 Address,{ Ciit1y,and Zip ft. m tt, j
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t(lft7r�'Cwit> 1 Q/r� V#�!
>;i Difd�rt'�r3�►
35 well field,6 hat/long)3 is sufficient)N 9 65� W 22.Ce ' cation v
'.4. i 13 41.42--1‘.1''' 2,11/4
6.Is(are)the well(s) Permanent or Temporary Signature of Gectrftcd Well Contractor Date
By signing this form,I hereby certifir that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or di with 1SA NCAC 02C.0100 or ISA 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 j . '
9.Total well depth below land surface: �-- (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 22@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use +''‘, 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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: -- - -
(i.e.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
l 13a.Yield(gpm) Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
Sterilene C 0
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: df_S- completion of well construction to the county health department of the county
where constructed. •
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016