GW1--02622_Well Construction - GW1_20240501

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. •
1.Well Contractor Information: '
Ricky Corriher
FROM TO DESCRIPTION •
Well ConuacmrName
2464-A /2-5E /`1S 3, S -
3ooft. 32-5'L ,
NC Well Contactor Certification Number • •
Frank A.Corriher&Sons Well Drilling,Inc. FROM TO DIAMETER THICKNESS MATERIAL
R, ft. in.
Company Name � �n � a � • ---- -- ---
' '
A/ ` -
2.Well Construction Permit#: FORM To -DIA M ETEER TirEfti ss MATERIAL -
List all applicable well consweaon permits ll e.UJC County,State,Variance,etc.) ..1-'-1 ft- 7 Sr ft. 61B Ia SDR21 KC
3.Well Use(cheek well use): 2 S ft / / ft' e 5/-in- / V Q (v
Water Well:
Supply FROM TO DIAMETER, SLOT SIZE TRtCKNF33 MATERIAL
Agricultural D 'cipal/Public ft. R inI
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. In
Industrial/Commercial
Irrigation FROM TO MATERIAL EMFI.ACEMERT METHOD a AMOUM
Non-Water Supply Well: ft. ft -
- Monitoring '.DRecovery ft. ft.
Injection Wen: ft. ft.
Aquifer Recbarge DGmundwater Remediation - _ _ _._�.. _•<-
Aquifer Storage and Recovery Salinity Barrier FROM rO - MATERIAL esseLscantorramino°
• Aquifer Test EIStormwater Drainage ft. ft
. Experimental Technology DSubsidence Control - ft. tt I. — .
Geothermal(Closed Loop) DTiacer IIYI L IL V._CIA —1-4 If IA d _
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) FROM TO os7RimON(eotor bantam,�vr«t errs. sty 1
n O tz 'too R �( `I/� tJ)
4.Date Wells)Completed: �/&Ot I well ID# Li v R —7 e ft' n'�l"tf "` -
5a.Well non: "?v `L 7 7 S of-4- ✓Coc_�
m i Z i moor'e -7?ft. as' 1 114-e c— -e
nn/701-7 ft. ft.
Facility/Owner Name Facility IDII(if applicable)d •
/.'7 c'o Mir'creek Gl��/el ideI'evSaad ft. - ft. ,--,---."�:� ,'1�FF.:1. •
Phys' Address,City,and Zip >z ft.
• ioik.ci,4 L5'7o3-S U1 L_.A '‘ 1w._ . rickplogr.seargag
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minntes/seconds or decal degrees: 11'.''':c,-,x',r 6 t}v .
(if well field,one let/long is sufficient) / ^� 22.C-. ..cot.': G.s( t'�
35•1590 70 N 80e 6 // 7 /Q w fl ( V'
0/ !' ' 9 i‘-27/`
6.Is(are)the wells) ermanent or DTemporary Signature of a Well Contractor, Dare
By signing this form.1 hereby certify that the wells)was(were)contracted in accordance
7.Is this a repair to an existing welt Dyes or li:lo with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standen is and thata
If this is a repair,fill out brown well construction information and explain the nature of the copy ofLhis record has been provided to the we/tweet.
repair under#21 remarks section axon the back of this form. T. 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nerEecary,
drilled: SUBMITTAL INSTRUCTIONS ' '
9.Total well depth below land surface: (f.) 24a.For All Wells: Submit this form within 30 days of completion of well
• For multiple wells list all depths if differed(example-3Q200'and 22@l00') construction to the following: I, '
10.Static water level below top of casing: 3 V (ft.) Division of Water Resources,Information Processing Unit,
ff water level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (am) 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: `
(ie.anger,rotary,cable,ditectpusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: • I 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test:Air 24c.For Water Supply&Iniectlon 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: 3 4 /r C.cP S completion of well construction to the county health department of the county
where constructed.
. From GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016
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