GW1--01695_Well Construction - GW1_20240315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
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Ricky Corriher oftVA. : 3 . ,,°z - c .M-
FROM TO DESCRIPTION
Well Contractor Name 1
2464-A ��oft.
('jl'Q
NC Well Contractor Certification Number x n
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name t i l
n ///JJJ y� �i��w�:"#si��E�l���( �use��e"oii�r= ' � .a r,�i.,
2.Well Construction Permit#: T/ r 1g al"I CI/ I FRO TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UI aunty.State,Parlance,etc.) r ft faf fL 61B I in SDR-21 eve
3.Well Use(check well use): _t ft. /Q:` ft• 1 sic-is /kV g t-+
14/
Water Supply Well: FROM TO DIAMETER SLOTIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. .in
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. PI
ustrial/Commercial OResidential Water Supply(shared) kis n ss *.w,t
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft fC '
• Monitoring DRecovery ft. ft. I
Injection Well: _ ft. ft. I ,
Aquifer Recharge ®Groundwater Remediation
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft. I
Geothermal(Closed Loop) DTracer S2-0 Y in > h . i TM .M t<
FRGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) a TO •DESC' ION color,ha Hess soivrook type,grain size,etc)
fLLtd ft. Ir
4.Date Well(s)Completed: D Q''Q/ ( Well ID# Lid. ft ft. ' 0 M
5a. ell Location: PP �� IL
Facility/Owner Name Facility
ID#(if applicable) ft ft.
/l50" G/tees edba/ac/eGli5.,,ame ft. ft.
Physical Address,City,and Zip ft ft.
County Parcel Identification No.(PIN) , 2 -- r i;.r r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: g q n c �}
Orwell field,o``ne��lat/long its sufficient) 22.Ce ' don: , I ` MA t 2024
35 .5 '7 N 80,, � �3 �' � _.
6.Is(are)the well(s) 'ermanent or Temporary Signature of 4csttl ed Well Conaactor 't5aic
By signing this form,/hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction Standa,ds and char 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 Ito provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also ittach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For Multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 3 0 (ft.) Division of Water Re sources,Information Processing Unit,
If water level is above casing,use'•+"/ 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:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
(� Air
13a.Yield(gpm) / Method of test 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
where constructed. i
Form GW-1 I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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