GW1--01570_Well Construction - GW1_20240308

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only.
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1.Well Contractor Information:
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Ricky Corriher -- - --- _ - --PROM 110, pi Y-Of -
Well ConnacoorName W alal �,ey r i2
2464-A
NC Well Contractor Certificatidn Number
Frank A.Corriher&Sons Well Drilling,Inc. _ .)'l„IgIAl AIMS rn(.4'11>sAll.11
'-� q1 ft. ft. In
Company Name / F R
2.Well Construction Permit#: „--- i ' ■)-.,I.'r � j:I y.,xN- - _
Liu all applicable well construction permits(i.e.UIG County.State.Variance.eta) Mill jjj it 6118 I in' SDR-21 vac
3.Well Use(check well use): /0 ft* /b • 3T
Water Supply well: •
Agticultnral - QM.:r aipal/Public ft. ft. . in.
Geothermal(Heating/Cooling Supply) I u •-idealist Water Supply(single) >t ft. in.
Industrial/Commercial DResideatial Water Supply(shared) -- — ---
Irrigation itrifallIIIMIMIIIII MA►TERIAL,v � ,,.gTrlj,,,,:liiii�r:(.;I'! .'v14i
Non-Water Supply Well: ft. ft ,
• Monitoring Recovery it ft.
Injection Well: ft ft —
Aquifer Recharge °Groundwater Remediation —
Aquifer Storage and Recovery DSalinity Barrier iittrIli . ■+;i;w10,a 1ayr Lar.u),a
Aquifer Test DStomiwater Drainage ft ft
Dr •
Experimental Technology DSubsidence Control ft. ft-. 1
Geothermal(Closed Loop) DTracer = .,
[�Odier(explain under#21 Remarks) ®© n .14 r,r„ r 5onesse r r . .. - `lei
Geothermal(Heating/Cooling Return)
'{ f�,�j oft. ,fio fir r,Pr
4.Date Wells)Completed:v~/ " well lu#. 2 R --of ft. mj_
Sa. IIIIMEIMPrellr-.Melilla
" O Well Location: Il/I
��V rVer5 R-Ertl/ rib) Zi e 1, - O c €- v`
Name • utility ID#(ifapplieab f ft. ft .. (,;_ s :"^
713 9 gam% s £ ,s44`s,�� �
Ph Admess car,and g ft. ft M A k 0 S o!4
�+
County Parcel Idennfration No.(PIN) !n(i.,riff sc;1 :r f Vey
YE.f1
Sb.Iatitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well field,one . is st fticient) (� 22. don:
35p N80�,j0C %., w r r
-0-4 7- --.21
6, are the a ermaaent or T S' of ' ed Well Contractor Date
�( ) wen( a i
By signing this form,I hereby certify that the well(s)awe(were)constructed in accordance
7.Is this a repair to an a daring well: Dyes or o with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construalon Standards and that a
If this is a repair,fill out brown well construction information and captain the nature of the copy of this record has been provided to the xr/!owner.
nrair under#21 remarks section or on the back of thisform. -
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 li 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 Webs: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3Q200 �
'and 2@100•) struction to the following:
10.Static water level below Q top of casing: 3" (ft.) Division of Water Resources,Information Processing Unit,
//water lend is above casing use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole dialer. (n.) 24b.For Infection 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: I` ,
(ie.anger,rotary,cable,duvet push,etc.) 1,
FOR WATER SUPPLY LIS ONLY: Divisions of Water Resources,,Underground Injection Control Progt urn; :
1636 Mail Service Center,Raleigh,NC 27699-1636 .__
13a.Yield(gpm) o Method of test:Air 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection ion type: Stenlene Amount d �l eapi completion of well construction to the county health department of the county
where constructed_ 1 T ,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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