GW1--03009_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: Mr
1.Well Contractor Information:
Ricky Corriher -
Well Canttacto<Name MOM TO r
2464-A R - R
NC well Camruct r Certification N --_ ._.• -
Frank A.Corriher&Sons Well Drilling, Inc.
.FROM To DIAMETER none ass id—Amelia,
ft. R is.
Company Name �o��S-� -•• - --_
2 well Construction Permit# FRa►t — TO {' DIAMETER TEOCI S€SS MAT RIAL
Las all applicable,ten oanv.tarn+pernsia(i.e.IIC.County.state.Variance,etc.) 1-1 ft. e- ft, yy in b' scn-21 ex3.Well Use(cheek well ace):
ft. 5 Z ft. C�s7-� h "A - /CV
Water Simply Wen: - - - —
i FROM TO MAMST'Blt SLOT SIZE TAICKT/�98 MAT®t1AL
■ • p-. o,. ��!n;crpa1IPublic R ft in
■Geothermal(1(Qli`e/Cooling Supply) ��i Residential Water Supply(single) it ft. bar
■ QRraidential Water Supply(shared) ___ _
-o False TO MATERIALD(PL EMPLACEMENT METHOD!AMOUNT
Non-- ter Supply Well: ft. ft. ---
Monitoring °Racovesy ft.
ft.well:-- ft.. R
Recharge C3cuotmdwater Remediation —__...__.
Aquifer Storage and Recovery DSalIDity Barrier PROM -ro MATERIAL MTCTHOD
Aye Test DStrnmwater Drainage R ft.
Experimental Tec mology Osubsideace Control ft. R
Geothermal(Closed Loop) °Tratxr
Geothermal(Heating/Cooling Return) DOtber(explain under eel Renradrs) rraoM ft. TO ft. may._auiraet del
4.Date WA(%)Completed: /(citge WellID#
Location'
sir.Weil : /3a W('7r�`�y V ft' R 1 l
I'np//';G%6 02 12 C �U " -3a�''� 151 4r? S '-
ft ft.
Facility/Owner Mane y (if•r T)zd - Y 2 0 ?0�4
�r f la � s!r
Address.City,and Zip R R
or✓4,9 �oo �/ - —•- ._.,:
Cory Parcel Identification No.(PIN)
Sb.Latitude sad ioagitade In degrees/minutes/seconds or deal degrees: —
(ffwell
fifield,metat/long is st�ci�) o Q p� 22.
6.blare)the weds) enuea �nt or Tea�orary Sigmare of Well C Date
By signing this forty.1 kerebv certify that the well(s)was(ewe)coursmried in accordance
7.Is this a repair to an misting well: °Yes or No with 1-IA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Stmrdards and that a
If tkas is a 1ef r.fell out blow well construction iafamation and explain the nature of the COPY of this rerard has been Prnvnda(to the well owrre.
repair wader#2I re,mmis section or on the hock of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT or hosed-Loop Geothermal Wells baying the same You may use the back of this gage toprovide additional well site details or well
construction,only 1 GW-I is needed_ Indicate TOTAL NUMBER of wellsconstruction detail You may also attach additionsl pages if Y.
drilled: SUBMITTAL INSTRUCTIOIV�
9.Total well depth below load surface: _ OS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf di a eat(example-3(200'andnd 2@100') construction to the following:
10.Static water level below top of casing: ! 0 (ft-) Division of Water Resources,Information Processing Unit,
If Cato level is above casing,use"+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: b fen-) 24b.For Iniectioa 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 condrnetiea method: construction to the following:
(iu auk,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(win) —1 Method et test err 24c.For Water Seemly&Injection Wells In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Dimfec loa typo Steden? /3 Amount 3 Caf S completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016