GW1--03296_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. 1111111711
1.Well Contractor Information:
Ricky Corriher — _-_.._-.-----.
Well Connector Name FROM TO nsgt■msoaci
2464-A ft.
ft
NC Well Cnnteaeeorc ;onNva$e ------- . .
Frank A.Corriher&Sons Well Drilling, Inc.
MDR TO DiAMt;Tpt -- .-- -
THICKNESS MATttttiAt.
It*
ft m
mom
�Y Nary
Lr
2.Weft a T'ermit# 0 a _ TO __
DIAMETER 'tmcxi�ss MATERIAL
List all afy ts,-,.hr.well construction pater(Le,UIC,County,State,Variance,etc.) Q' ft- s 118 �' Sce-21 P.m —
3.Well Use(check well use): f. ft in. —
Water Supply Well: --
• 1,... FROM TO INAM6rat tid.OT SIZE THK7 MAT®HA1,
�I#inicipai/Public ft. ft. in.
!Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
II Inclustrial/Cominercial DRcsidffitial water Supply(shared) —
!Irrigation FROM
TO MATERIAL Md:r_. • -:
:
HOD:AMoaxr-
No*-Water Supply Weft: ft. ft.II Monitoring Monitoring °Recovery R ft.
Injection Weft: _
III -,,.- : Reese 0 Remedrauan ft ft
. - S and Recovery _-.
Battier PROM To MATERIAL __--
a Test DStormwater Drainage ft. ft. EMPLACEMENT METHOD
■Experimental Technology DSubhidence Control ft. ft. -
a - (Closed Loop) [:Trace =
II -••,-. (Heating/Cooling Rearm) Other(explain under#21 Remarks) PROM TO oPScatrmort(4+.r a.anoel cps olio gm,.le)
{ ft. ft.
4.Date Weikel)Cow: ___ Weft m# ft ft.
set.well Location: , V ` A s ft. ft.
P cthty/OwnerNeme Eno ?//r/ iL ft. r ,{
��-I:1 dr gc90 casa� . � ft .
City,and zip 't ft.
- owail l --
Cam' Parcel Identification No.(PIN) —
Sb.Lt la&and longitude in degrees/arinutes/seconds or decimal degrees:
`� (if well$tld,one fat/long is soft :at) 22,7sZ.3J �.. C f 80 !% / L�_() W {( /��/l��1it/`tiL /6.Is(are)the well(5 Kmaaent or DTetaporarySi�anre ofWell Contractor p
By signing this form,1 hereby co tify that the well(s)war(were)constructed in accordance
7.is this a repair to an existing weft Dyes or No whit 15A NCAC 02C.0100 or 15A M IC 02C.0200 Well Construction Standards and that a
If this is a repair,fill ma Morn well construction information and expiau the nature of the copy of this rera d has been provided to the well owner.
repair wider#21 rearms section or on the back of this form.
23.Site diagram or additional well detaSs:
You may use the backof this page to provide additional well site details or well
&For GeoprebdDPT or Closed-Loop Geothermal Wells having the same
construction,only 1(iw-1 is needed tadicate TOTAL NUMBER of wells won details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below La surface: 1 65
Land
For nmhiple..ells lidant deptks f d (ermnple d(a3200'and?®I09) Ott 24a. For All Wells: Submit this form within 30 days of completion of well
O construction to the following:
Static10.Sic water level below top of casing: (ft-) Division of Water Resources,Information U
If�waaer level is above casing use"+-
1617 Mail Service Center,Raleigh,NC 7
11.Borehole diameter: ('' fuse)
24b.For Inieetie■Wells: In addition to sending the form to the address in 24a
12.Well construction mod: Air Drill above,also submit one copy of this farm within 30 days of completion of well
(i.e.anger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resourc Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(Sp®) I 0 Method of test Air 24c.For Water Supply&I section Well. In addition to sending the form to
�^p the addresses) above, also submit of
days of
1311).Disinfection t71c sterlene Amount -4 eat
S completion of well consnvctim to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016