GW1--01560_Well Construction - GW1_20240308

I
WELL CONSTRUCTION RECORD(GW-1) Fat-Internal Use Only:
1.Well Contractor Information:
Ricky Corriher * , T '1.; g .;� z i , IrZ . PI
FROM TO DESCRIPTION
Well Contractor Name 0U A,3_.
2464-A / ft• / l�C.�frt 35 GA
d.
NC Well Contractor Certification Number • � � - 7'
.tea �'... ._. � .. .. ._.,
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER ' THICKNESS MATERIAL -
ft. ft. 1 in.
Company Name '. . ' . W. A
�" `� �� ;III �� ,t��;�_.������Ud.
2.Well Construction Permit#: 3" � / =_' FROMOy TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) .1"1 ft )l( ft 61/6 ' 1°' SDR-21 PVC
/3.Well Use(check well use): 5/ ft' t ft 43657 'n `/8( • c/
O :., . • em s ' l5":' � . VA-1- 101028-Mg
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural ° icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
I Industrial/Commercial 0 Res idential Water Supply(shared) Iittoziovirci-:. .. t, - a ^4 f, *,_ .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft ?'
• Monitoring ®Recovery ft. ft.
Injection Well: ft ft.
A;Aquifer Recharge 0 Ground water Remediation v..N
Ii Aquifer Storage and Recovery 0 S a lin ity Barrier FROM TO MATERIAL ' EMPLACEMENT METHOD
• i Aquifer Test DStormwater Drainage ft. ft.
I Experimental Technology 0 Subs idence Control ft. ft. !
I'
t Geothermal(Closed Loop) E3Tracer ,,, " firtiiiiti+ {r°° : . G.SWO
R Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) FROM TO Desct;IpTuC�eotor nartness soiVroek type,grain size,etc.)
p l� �/ ft tJG� ft. J�e r�104-
4-Date Well(s)Completed:P L 1 8 ! Well ID# �a.. 24) ft. 5 .l.
SO,hji;ic
ell Location: y'� a �70 ft. �� ftft s4.1 /f I/
V c 2Y've/Of e i J eL7%^!�/r 615 `''� ft /4.5 '.. I(fie - 16�2t / i�
vto)(
Facility/Owner Name _ Facility ID#(if applicable) ft ft. 4 1 t y '�9_,y
`7 (f 7 Free,,,,--e /4 kawfri okS .2201 ft ft
Pb ical Address,City,and Zip ft ft MAR O 2024
County Parcel Identification No.(PIN) i pktiriirlOG
' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) "� 22.Certifi don: '
35,.c35'10 9 N 80' 6 ' fr v ©0 �1' if, 0 ��Z� `
/ --a27
6.Is(are)the well(s) ermanent or Temporary Signature of CeiEWell Contractor 1 Date
By signing this form,1 hereby certift that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or to o with 15A NCAC 02C.0100 or 15A 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:
�j� SUBMITTAL INSTRUCTIONS !
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 f different(example-3@200'and 2@100) construction to the following:
�/�y I
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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 0 (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: j
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) 30 Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
e� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount: d completion of well construction to the county health department of the county
where constructed. 4
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016