GW1--01440_Well Construction - GW1_20240301

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C'rrn Farm
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: • -
1.Well Contractor Information: '
Ricky Corriher 14.WATERzoNss
Well Contractor Name FROM TO DESCRIPTION
t ld / t
2464-A ���
ft. ft.
1
NC Well Contractor Certification Number 15.OUTERCASING(for,niuld eitsedivells)OR LINER Of ap IIcable)
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 'in.
Company Name g//}/, ,16.INNER CASING OR TUBING,(geothermal'closed loop); '-' `;' -,
2.Well Construction Permit#: g v`a��( (/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft' ft' 6 1/8 i in* SDR-21 'PVC
3.Well Use(check well use): • ft. ft. in.
,12.SCREEN ;r ..°,'
Water Supply Well: % FROM TO DIAMETER� SLOT SIZE- THICKNESS MATERIAL
$Agricultural nicipal/Public ft. t ft. in.
'J Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
I Industrial/Commercial OResidential Water Supply(shared) 18:GROAT.'
XI litigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
*Monitoring ORecovery ft. ft.
Injection Well: i ft. ft.
%Aquifer Recharge Groundwater Rcmcdiation
.,19.SAND/GRAVEL PACK(if applicable),
$i Aquifer Storage and Recovery SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test : 0 Stormwater Drainage ft. ft.
N
Experimental Technology D Subsidence Control ft. ft.
I Geothermal(Closed Loop) Tracer a 20.DRILLING LOG(attach additionalsheets'if necessary)e�"4.1 _- - -,�
' a Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(coloq rdness,soiUrack type grain size,ete.l
V 0 ft. [ ft.
�/�( J�l,�l
4.Date Well(s)Completed:2—/G r° Well ID# �2,7 J�, ft. S�j� '_ a0c.,,/( (°-'
5a.'Well Locationon�/� 3 '7 ft $ ft. 6 '''e- d- (!/tL 1Z_ f _/L..
teary kg,k4//sO�i /eft. - ft.
Facility/ caner Name Facility ID#(if applicabl ft. ft. 4 \L C.L;VI..."
�� �� � ft. ft.
Physical Address,City,and Zip
y �° ft. ft. iMAR 2024
nn 21.•REMAR1CS,. Yttf* T/5 i 1•s••
County Parcel Identification No.(PIN) DitaQBOG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degree's:
(if well field,one lat/long is su tent) 22.Certifi lion•
35�� � �� 1- N 80m � '�� � w
. /' >-e4,cjw 2
6.Is(are)the well(s)7 Permanent or oTemporary Signature of Certi d Well Contractor i 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: OYes or No with iSA 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. 1 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: 0 (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 2@100') construction to the following:
10.Static water level below top of casing: © (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service�n'ter,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: 1 construction to the following: 1 '
(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
-7 Air i
13a.Yield(gpm) 1 / Method of test: 24c.For Water SuppiV&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
13b.Disinfection type: Amount: 0, :=/(9g completion of well construction to the county, health department of the county
1 - where constructed. 1
( II J
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016