GW1--01562_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD(GW-1) -For Internal Use Only:
•
1.Well Contractor Information:
Ricky Corriher :• ix'> _ 0.. 2 : .•4 . - :- . .,?„1.)--,
FRO ,, TO D ON
Well Contractor Name t �� n
2464-A ���'' o soi
ft. ft.
NC Well Contractor Certification Number `5':,x }r:a , i4 F ,,, t;ai*,,N ett. a::a r.
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I, in.
sP+,,
Company Name /r,/r; �j - .-i,�xzftei :, .:,E'.pa a ;;S i:::_4"L.e .. x ' s
`UD//11 "� wx IAL, 'c;: b?
2.Well Construction Permit#:' �-/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,County,State,Variance,etc.) +'1 ft. r-y ft 61/6 / -f In' SDR-21 we
3.Well Use(check well use): d Lift. . / ft-
_/ ' , 04
' _
;d'ro� ._,_ice- •7`:s°> az' "r2�.i ;�,.i£�a-+=mot akc.•S� file.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL in
Industrial/Commercial °Residential Water Supply(shared) ,:s< 0 _, A, -tom
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft
• Monitoring °Recovery ft. ft
Injection Well: ft, ft.
Aquifer Recharge °Groundwater Remediation
it s':,. x 8.r ,nG t -' x-'.-r?tS° ,%-.7 c ` r.,�."i``" .......1.1n
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• Aquifer Test 0 Stormwater Drainage ft. ft
Experimental Technology Q Subsidence Control it. ft.
Geothermal(Closed Loop) ['Tracer tin-e: , _ . g.,, :• .,-, =.. -x 5 ..
FROM }PTO ' DESCRIPTION(color.hardness,soil/rock type.grate size,ate.)
Geothermal(Heating/Cooliag Return) Other(explain under#21 Remarks) b a. 7D ft. , Aires
4.Date Well(s)Completed p��a.9 / Well ID# l) ft- ,r‘ ft' 5 ) a
Sa.Well Location: �/�/ '/ 8-6 ft /2s'-rt: /J Il�.,e C/Z'
arc4/3 of-de
�0 Fac'' /Owner Name r, Facility ID#(if applicable) f ft k"r L�t l+.
69 / re z e,ed'lC.:3,�n mis v ft. ft. 0 S 20Z4
Ph Address,City,and Zip n /1 ,`3 -
�� V ''R 04`F r#e:.l F'r.X`4, 3 .L°Y axl_.'i';'''''r'sa' ��-,.•':;_"i.^.e.'j'� •_'ev,0f;g1 'Lc:.
,Lii..Y •
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) / p C� /7/ 22.Certi lion:
3505356'3 t N 80, lob / •3 W
..,. ,fA, ... 0 s t,,,..,4.,- a—Q9---R.
6.Is(are)the well(s) rmanent or Temporary Signature of Cettitl'ed Well Connactor ! Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or o with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repo Jill out brown well construction information and explain the nature of the copy of this record has been provided to the null 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-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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use''+'tir 1617 Mail Service Center,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: construction to the following:
(ie.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
13a.Yield(gpm) 6 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
13b.Disinfection type: Sterilene Amount: - completion of well construction to the county health department of the county
I
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised2-22-2016