GW1--03900_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: lir
I.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTIO_N
2464-A `���ft. e .,C L `
6,66 3 ,.J
NC Well Contractor Certification Number --"- - -Frank A.Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER TIICKN S-S MATERIAL .
ft. ft. in
.
Company Nam 7�/ {
2.Well Construction Permit#:3 / FROM TO DIAMETER 'Imclavlss MATERIAL
all applicable wet construction permits(i.e. UIC,County,State.Variance,etc.) f ft• !Y4 ft 6 1B M. SDR-21 we
3.Well Use(check well use): 2-L( ft. 2 YR 6 51 11'— d c.` lei
WaterWell: =,>r--;
SupplyFROM TO DIAMETER SLOT BITE THICKNESS MATERIAL
Agricultural OM icipal/Public ft. ft- is.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. In.
Industtial/Coamtercial °Residential Water Supply(shared) ,: _. ...... .,....:
IrrigationFROM TO MATERIAL. EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' ft
Monitoring DRecovery ft. ft. — —
Injection Well: ft f. —
Aquifer Recharge OGroundwater Remediation _ — ------................ .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACE114' rMETHOD
Aquifer Test 0Stormvrater Drainage ft R. —
Experimanal Technology E3 Subsidence Control R- ft.
Geothermal(Closed Loop) OTracer — -.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remadta) FROM TO �(watt�trri�,aaahaekt�,�ai etc)
4_Date Wdks)Completed: ' �! Well ID# /,0 � a �7' el v-(. k r.... -
Sa.Well Location: t 26 ,6 f , '`Z63 '-4' Crl'( _.. .,('`t�� r.,?je
Facility../0 Name Facility IDM Ctfappliabk)
ft. ft./,yS. /1-/ottv1<gAtA(y eir-i;,►G It ft. SUN 2 8 2024- ft.
Phyisal Address,City,and Zip
O` Vl /V / ". A.r.r.
G it/C�) ---- --- .. __
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,am pat/long is sufficient) 22.Ce lion:
354 b a Il 0 CJ N 80 E/ y 7 w _ .4-2-14-7 _t2 Li
6.blare)the well(s)permanent or Temporary Signature of Well Contractor Datc
Hy signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or to with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
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-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C3- (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multipie wells list all depths t'different(example-3Qa 200'and 2@l00') construction to the following:p
10.Static water level below top of casing: 7 S' (f(-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Injection Wells: In addition to sending the form to the address in''4a
Air Drill above,also submit one copy of this form within 30 days of completion of welt
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(Rpm) C-- Method of test: Oar 24c.For Water Supply Sr Injection Wells: In addition to sending the form•.o
the address(es) above, also submit one copy of this form within 30 days of
r.
13b.Disinfection type: Stenlene Amount S completion of well construction to the county health department of the count.:
where constructed
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource; Revisal 2-22-20!e