GW1--01439_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: ; ,
Ricky Corriher ;40► MMMAr* ..t_.uu IM.4-3 LW4
FROM TO DESCRIPTION
Well Contractor Name / / t 2t. 111 5 CI
2464-A f o ft. ft
NC Well Contractor Certification Number . r R • .r.q- ,y;
Frank A.Comher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft i in.
Company Name 11
®� �0 liK' ” @1Ca ftilla ' .: .- ..ar ''_' 1 ' 'i �aa <r i
2.Well Construction Permit#: (lam FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC.County,State,Variance,etc.) �"l ft. pi y ft 661/8 I in* SDR-21 eve
3.Well Use(check well use): lb t''�ft• /O ft' d S < f 54 3V I(J
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural - lif icipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) f,c 'esidential Water Supply(single) ft ft. hi.
Industrial/Commercial °Residential Water Supply(shared) e.:cr,m „.a - � �,;v
�4f$'}.`f4fti3K'is»'.:�.�'i��� =a. ,4=.. ,.�: ��..c:-�:;.. .vic.a_.::e�.. .s,,..,aR .x`�.*rv..�,-�,
Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. It.
Monitoring °Recovery ft. ft
Injection Well: It. ft.
Aquifer Recharge °Groundwater Remediation
Ifd9'`IS NWORAS'�G nt fiLapilEade) . 4 244SMV?,fi".::._ k
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) . ,OTracer .` "-`s "�i sti> + i' ` _ 4
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEscjq/� TIC (eol hat:psoil/rock type,grain size,etc.)
j D fL fp ft. I`p J)4n�l�L
4.Date Well(s)Completed:t ✓"9-' / Well n1# 4 e) fr" 5)J ft' SA, ,(`14
5a.Well Location: C(� It. lUj° ft. S,1 t ,
f c ft 3 OSr i. />[CL,e `-- 1' <<'L V_.1N.,s'e-
Facility/Owner Name Facility ID#(if applicabl f.0 4 ft. ft.
7gc5-076(6104o i lute, P• ft ft
Phys' I Address,City,and Zip ft. I
County Parcel Identification No.(PIN)
�i:i tU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �t Y 2027
(if well field,one tat/long is sufficient) 22.Certifi 'on:
35,56 93 7 N so,,v-/03 c./ w a/12 aen o
led� r
6.Is(are)the well(s) ermanent or Temporary Si of Cenifi�d well Contractor Date
By signing this form,l hereby certff that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with ISA 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 I GW-I 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: 3 a� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2(100') construction to the following:
10.Static water level below top of casing: ..-.74CY (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
12.Well construction method: Air Drill
above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) q Method of test: Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Sterilene completion of well construction to the countyhealth department of the county
Disinfection type: Amount: e� �� P eP
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcels Revised 2-22-2016