GW1--01791_Well Construction - GW1_20240320

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well Contractor Information:
Ricky Corriher : : a a'. ,' ,0`'.-a`ll".«;{' 4' -:t-zz' f:"=,:.r 4 ` x.. *..za
FROM TO DESCRIPTION
Well Contractor Name /-
2464-A rl D� `7 �/
ft ft.
NC Well Contractor Certification Number ,t ift 5', #.;s z-i.,.--„ram . --.="z h_. r' :(1'•,' t. . < %w
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER 1 THICKNESS MATERIAL
ft 1 ft. JJ in.
Company Name q
, M3-s A ,ar .Ti a ,(If_f a . - 41. :%---al
2.Well Construction Permit#: FROM TO DIAMETER
DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) l 1 ft. J(r?"p K' 61B / in. SDR-21R- we
3.Well Use(check well use): /D ft ' t�ft. S%— `,Y d' - <V
5°47,,- d 4.`i; ,. _"'a '7-4;;ne. :ar—^+.' i, ate-* `'''d
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ju Agricultural D cipal/Public ft, ft. in.
R Geothermal(Heating/Cooling Supply) Ellesidential Water Supply(single) ft, ft. in.
A Industrial/Commercial °Residential Water Supply(shared) t! ; i . .w .
fir.. � �t.�;.,� ��:�f �" �'�Z "-�.".`a�y.'�v"�d.� �tx.-.� rs'=
i Irrigation PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring °Recovery p- ft ft.
Injection Well: it ft.
I:Aquifer Recharge -lGroundwater Remediation - -
if Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
'I Aquifer Test 0Stormwater Drainage ft. ft
`II Experimental Technology 0 Subsidence Control ft. ft. -
R Geothermal(Closed Loop) [Tracer
TOf<Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) .�,,°.,M lip ft. DESCRtyTtoN tyotor,noes sou type.graso sue,etc.)
4.Date Well(s)Completed: )t i Well ID# /0 ft A(/ ft' O'/Dt�'j �
5a.Well lion: 0D ft. ld�ft. s A-c/` p�
,1 t�gi7 IZ,0,t t� �l')/1 %tr2� /35ri /�4 — ,112t�. '
Facility/ ame,/�/yy� �y Facility ID#(if applicable) ft` ft'
Ph Address.City,and Zip 'V ft. ft. r'_ - r` ,(_�.... `
Ate Q�7z�G1 7 County Parcel Identification No.(PIN) MAR 9. 0 2021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiel one lat/Ioong is sufficient) / / 7 p 22.7ilion: Ifl i i ri-,a+<=1 Pr'-;'"T'-'j L7?
•
35r rJ ��d\ N 80" tJ( G" (/� W r n / [WIC .. yC7 3 ` )�-�
6.Is(are)the well(s) rmanent or Temporary
Sigrelu e of CertifieQ Well Coontracctor Date
By signing this form,1 hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYa s or o with 15,4 NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fall out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2!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: /3✓ (fG) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3(4200'and 2@100) construction to the following:
10.Static water level below top of casing: 1 V (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: &/ (in.) 24b.For Iniection 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:
(Le: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) / -7 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 9.' J completion of well construction t' the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016