GW1--01443_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: Pkm
1.Well Contractor Information:
Ricky Corriher 2.
Well Connactor Name
2464-A
ft. ft. ! / .
NC Well Contractor Certification Number k
Frank A.Corriher&Sons Well Drilling, Inc. il +ty wi 3C-k7Mil MATERIAL
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Company Name (.� 7.a. xr-- -roe .. z ;.., , •S-zr''4'3- "` 5
1,
2.WeIIConshvctioaPermit#: � / :I K� ir,+ry,..+x:i� MATERIAL
List allapplicable well constructionUIC, is
permits(i.e.(' County,state.Variance,etc.) �� i r 61/8� SDR-21 , we
3.Well Use(check well use): / -
Water Supply Well: v. Ls
n�.,.� •'—?m r" 1piini�:+y.,a1 MATERIAL
Agricultural, p ,' ,'cipal/Public ft, ft. Iin:
Geothermal(Heating/Cooling Supply) OF Residential Water Supply(single) I
ft ft ern --
Industrial/Commercial °Residential Water Supply(shared) F,.,.�' ��'���� ��.,`�" "sue�� �"` ��-.*�a���:���v�=
IrrigatioII t ' i r EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft
• Monitoring °Recovery ft. ft. I
Injection Well: V
ft. ft.
Aquifer Recharge °Groundwater Remediation �_a.
Aquifer Storage and Recovery Salim Barrier . ' r
�531:1111111M1111 aa„r9 Ai,,L.Ili.Zu 1.1vt.»1.111
Aquifer Test DStormwater Drainage ft .
Expeiiwental Technology [Subsidence Control ft. • ft.
Geothermal(Closed Loop) DTracer x =- '" "` " ,-1- -'t,- -
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. DESCRIPTION abr darn rack r• .,. .1
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4.Date Well(s)Completed: )! Well ID# 15Mal -(&7 ft.
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ell Location: k< ra ,
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Facilitir
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Lei-3 I F ihty MS(if applicablee) ft. ft. 1.1111.11111111.111111Mili tile. z42, (cormeoh!s ft. .. .... ., ..
Physical Address,City,and Zip ft-
go Val %b '/' _i 72 �.,L : �- _a
County Parcel Identification No.(PIN) I,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I'
(if well fiee,one laas/long is sufficient) �(
35 of la/ / / N $O m V 22.Ce on: c/
,&,,,,,,,,,j ' V-,9 7--
6.Is(are)the well(s) ermanent or Temporary Sigr>a of Cer rf d well ContractorDate
signing this form,1 her n �`By 8 g � hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repay 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 remanla 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:-0 ' � SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface: ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jdifferent(example-3@200'and 2@100') construction to the following: P
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing
If water level is above casing,use..+^ 1617 Mall Service Center,Raleigh,NC 27699-1617 Unit,
11.Borehole diameter: lP (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
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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 Sum*&Injection Wells: In addition to sending the form to
Sterilene �3G- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction,to the county health department of the county
where constructed. I: '
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FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resouetea Revised 2-22-2016
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