GW1--01565_Well Construction - GW1_20240308

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. •
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1.Well Contractor Information:
• •Ricky Corriher
wellCormacmrName ;, l D Tio'iv
'
2464-A ��/ i �� 3d
ft. ft: E
NC Well Contractor Certification Number • — —.-
Frank A.Corriher&Sons Well Drilling,Inc. iii• D1Mik-TER ;: .so Ai1111j2
�j7 ft. ft. I m..
Company Name (O : 2
2.Well Construction Permit#: r� . .,,
.. ,,n.tr.+� , .,,:.,,,,. - =
List all applicable null construction permits(.e.UIC County.state.Variance.ear_) ISMII /0 ft 61/8 I, in* SDR 2t
3.Well Use(check well use): 0 ' lD- ft' ! ' 1O' I Q (�
Water supply Well: _ .� --
�_-o� DiAM6=,WI...4 �r,llit ICo(.,.I NMIEMMEN
Agricultural unicipal/Public ft. ft. in. -
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n ft.
Industrial/Commercial °Reside itial Water Supply(shared)
Irrigation )1 MATERIAL. ill,t. ,T• t:t.! „i.,r:i, I'1..,t;ThaI
Non-Water Supply Well: ft fr. I`
Monitoring °Recovery ft. ft.
Injection Well: ft.
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery ['Salinity Barrier itr,'. entninlil. ■a,:t:wT.a,ra:ri t.,r ,jam
Aquifer Test ° m Storwater Drainage ft. t ft
Ell Technology °Subsidence Control ft- ft-
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Geothermal(Closed Loop) Tracer
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) © fe. ginarmagnagimmon
4.Date Well(s)Completed:3 5 '/ wen>D# IMI �� d�
Location: a ,
saWay)
v1/ a )'er3 gf al Oct"L�n A c V WJr - ✓J vi
/OwnerrName t a F • t. (ifapplieab ft'
' 51i Br;,,,,,,s K _S., t,A k
Ph Address.City.and Zip VC/
LAo O
(1'C_ — ft. '. — — __ .
Cmmty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
35 seta,one tg)r2Oag is sufficient)N 80.e 5dt e 0L W z2 bon: e
• 6.Is(are)the wells rmanent or Temporary Signature of ed Well Contractor ., Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance '
7.IS this a repair to an ex fisting well: °Yes or o with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and Sun
Ifthis is a,epaw,fill out brown well consouciioa information and explain the nature of the ropy of:hit record has been provided to the well owner_
repute-raider q21 remarks section oron the back of this form. -- - - 23.Site diagram or additional well details:
8.For Geopr obe/DPT or Closed-Loop Geothermal Wells having the same .. You may rose 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 mayalso attach additional pages if necessary.
Brined SUBMITTAL INSTRUCTIONS 1
9.Total well depth below land surface: •, ✓ (ft-) 24a.For All Wells: Submit this'form within 30
For imdripie wells list all depths fd Brent(example--3(0200'and 2(a)100') construction to the following. d of completion of well
10.Static water level below top of casing:. 31/ (ft.) Division of Water Resorirces,Information Processing Unit, -
lfvaterlevel is above casirrgjuse"+"7 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: MO M.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Drill -- above,also submit one copy of form within 30 days of completion of well
12.Well construction method: construction to the following: j
(ie.auger,rotary,cable,direct Pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY';WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �30 Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 .Q/. the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: Serene - Amount: a �- completion of well construction to the county health department of the county
where constructed. : • -
Form GW-1 - North Carolina Department of Envi onmental Quality-Division of Water Reso I ! Revised 2-22 2016
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