GW1--03003_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only Mr"
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1.Wei]Contractor Information:
Ricky Corhher
PROM To DF9CRW11ON
Well Contractor Nam
e . Ae ft" QZ(G't Y7 Wi/
2464-A f. ft. —"J
NC Well Contractor Certification Number _.__.___, ..._ ..--------_ _..__._ -- -.._._- _-----;
-
Frank A.Corriher&Sons Well Drilling, Inc.
FROM To _ ..._. .MARTI __._rocs s._ Mlenut AL
ft ft. um.
Company Name — —— -2.Well Construction Permit#: Lila'2 R 0 IntO" T° DIAMETER THICKNESS MATER/AL .
List all applicable well construction permits(Le UIC,County.State.Variance,etc.) .1 • R- / ft' 61R b'
/ ,7�/, SOR 2t utie
3.Well Use(check well lase): ft. &-se): • 7 G C./ !/
ft.
Water Supply well: FROM TO DIAMETER sun SIZE TH!Q(NssS MATERIAL
■ . 0 Zcrpal/Public ft. ft. in.
In (Heating/Cooling Supply) - Water Supply(single) tt ft. M.
■
tial water Supply(shared)
•Irrigation FROM TO MATERIAL EMPLA LEMEN 1'MEtHOD!AMOOPIT
ft. ft_
Non-Water Supply Well: _
■Monitoring °Recovery It ft.
Injection Weil: R
Grotmdwaber ---- - -
• �.,r : Recharge -
■Agui Storage and Recovery °Salinity Barrier -PROM •TO MATERIAL Estrt AOSMErrMieriroD
■Aquifer Test °Stormwater Drainage ft. ft
■ .,_-:.,:,:, Technology °Subsidence Control ft. ft.
■ _, „-. (Closed Loop) 13Tracer
PROM To mea
«
,• ner , • .sue)
■Geothermal(Heating/Cooling R Return) DOrt/lter(explain under 421 Remarks) a, ,�/i ft. ,0 �--
4.Date Weihs)Completed: , 4/` !,yWen ID# R �(/�n ft-Y sa.well Location: A I'/ d(! /aS c ft 710 ,' ail /7 /L
Om6> „tit i/'e„..S/m.a47/3 ft 3f/5 a /toe . l7/cri.
Facilit)/Own r Name Fealty ID#(if applicable) ft ft.
Logy i 30 - scP/ti-�,241 sctlt'sa,r pt C a n ft. � 1 0r074,?/ � tz ,z
Physical Address,City,and Zip -
ROWCt.n SaO 73 _=
County Parcel Identification No.(PIN)
sb l.atitiade and ioogitade in degrees/min' or decimal degrees: '
(if well field,one lnt/iong is sufficient) 22.C don:
35. (� aO � `1SN 80, a >J w Well
O , "'Z___:2_9_7 e27
Contractor
6.b(are)the weli(a)theer Q maneat or Temporary Signature of
BY signing the form,I hereby c.,ttfy-that the well(s)was(were)constructed in accordance
7.15 this a repair to an editing well: DYes or No with ISA NCAC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair.fill ova born well coisstruction information and explain the mauve of the ropy of this record Gas been provided to the well owner.
repair rods#ll r+aamrlt section or an the bock of tics form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Gootberval Wells having the same Yon may use the back of this page to provide additional well site details or well
construction,only t GW-1 is needed. Indicate TOTAL NUMBER of wells construction � You also attachadditional pages if necessary.
do SUBMTITAL INSTRUCTIONS
9.Total well depth below had surface: 3 a_C (ft-) 24a.For MI Weller: Submit this form within 30 days of completion of well
For muh/ple wells list all depths 'different(ermrryle-34200'and 2Q1001 Epp to the following
10.Static water level blow top of caring: 3 D (ft.) Division of water Resources,Information Processing Unit,
1f,aater level is above casing,use"+' 1617 Mau Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (7 (in.) 24b.For Injecton Wel►s: In addition to sending the form to the address in 24a
Air Drill above,also submit one copy of this ftnrn within 30 days of completion of well
12.Well construction method: construction to the following
(i.e.auger,rotary,cable,react 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(gym) 6 Method of test Air 24c.For Water Snooty&Injer:lioa Wells: In addition to sending the form to
3the address(es) above, also submit one copy of this form within 30 days of
13b.Did of type: SharleneAmount G4/0-S completion of well construction to the comity health depattmeat of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoon:es Revised 2-22-2016