GW1--03008_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: 1111111111111
1.Well Contractor Information:
Ricky Corriher
DES
CRIPTIONWell Contraetcr
2464-A rime R l e. f� '�'
R ft.
NC Well Contractor Certification Nttmbe i -. - - -
Frank A.Corriher&Sons Well Drilling, Inc. "ROM ft. • TO ft. • DIAMSTER
u maims stew>slai.
ConpanyName �O z `/S� __ === —
2.Well Coesfroctien Peru# FROM ro (� DIAMETS macaw MAt�tIAL
List all applicable well constructionpermits(i.e UIC.County.State.Variance,etc.) t/ R y / ft' 61B _ SOR-21 rye
3.Well Use(cheek well use):
Water Supply well: PROM To IS Asai es swr SIZE Tnraaass MATERIAL
R v „.. O "oipal/Public ft. ft. to
■Geothermal .eminrJCooling Supply) Residential Water Supply(single) ft, R M.
! i a I - • Water supply( —
II Irrigation FROM TO MATERIAL. itlie acTatE VT METHOD!AMOONt
R R
Non-Water Supply Weil:
JI Monitoring DRecovery __._ ft. ft.
Injection Well: it. ft.
a
Recharge OCaotmdswater Remediaai«t
II Aquifer Stange and Recovery °Salinity Barrier PROM -TO MATERIAL t,.;,•�•.:,,•e a• e .e'11
MI Aquifer Test OStormwater Drainage ft ft.
■Experimental Technology OG,In-itionce Control ft. ft. -
(Closed Loop) QTracer - '- -
■Geothermal(Heating/Cool ng Return) OOther(explain,order#21 Rematics) • cm ft. ro J R ,otl te.br3l +•�+•�ram. .t..tse.a)
�l yL `- '
4.Date Well(s)Completed:y�-/a7 g o?V well inn 'c) " q5 0 a- S /Cx-L
Sa.wee Location: PA-laid (r 1 jZ/ ft' /U n ye, L.L ,1 9_ mo/eo C,t /ass L Z c �'c) ft- /l'e2ft- .ti e(yf'y(�-
D FaethtylownerN,ame Facility» (if applicsblQCV0e9 ft. lfJ �4 e 4-- /f 5���'
/2�SSc i.&d2 /.2 /.��k� ft. R
Addtaa.City,and Zip ft. ft .
1Coi�r:/j
Cons Parcel Marion No (env)
Sb.Latitude and longitude in degreesrmimutes/seconds or decimal degrees:
(if • field, W/brg is sufficient) 02 'ITC'S/ w 22.Certification: 0 ` 5 5/
,e--v"%
S of Well Contractor6.1y(are)the weI(s ermaneut or OTemporary Dade
By signing this fora.I hereby cn t3 y that the we (s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or o with I5A NCAC 02C.0100 or 15A NG4C 02C.0200 wen Cattinetrat Standmds and that a
jdeis t a repair...All ovt known well construction information and explain the nature of the ropy ofthis record has been Drew:lel to the sell owner.
repair twill,#21 monmb section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprsbe/DPT or Closed-Loop Geothermal Wells having the same You use the back of this page to provide additional well site details a well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction detains_ You may also attach additionsl pages if Y.
drilled: SUBMITTAL INSTRUCTIOM:
9.Total welldepth below land surface: / 9' (ft-) 24a. Far AU Wells: Submit this form within 30 days of completion of well
For multiple wills list all depths y'different(esemnple-3W200'and 2®1001 construction to the following:
10.Statie water level below top of casing: 90 (IL) Division of Water Resources,Ink renal=Processing Unit,
If water level it above casing,use"+• 1617 Mail Service Center,Raleigh,NC 276 9-1617
m 11.Borehole diameter: Cm) 24b.For Injection Wells: It,addition to sending the form to the address in 24a
Air Drill eve,also submit one copy of this foul,within 30 days of completion of well
12.Well cootruetien iodine construction to the following:
(i.e.anger,relay,cable,direct posh,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mae Service Center,Raleigh,NC 27699-1636
13a.Yield(ERm) I G Method of test Air 24c.Fen Water StmtttY&Injection Wells: In addition to sending the form to
Sharlenethe address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectioa typo Amount completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Eanromnental Quality-Division of Water Resources Revised 2-22-2016