GW1--03902_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _ -P . .. .77-7---7-77-7. -
FRom NE DFSCRII'rION
Well Contractor Name
2464-A S.
. _ el
NCWell Contractor Certification Number
Frank A. Corriher&Sons Well Drilling, Inc- �� DIAMETER .. ._
la
Company Name 2.Well Construction Permit#: 1:1C 5' 3 -.^ - z '2/ '1 DIAMETER
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) ©MSE 6 11I8 'n. SDP-21 eve
3.Well Use(check well use): O.
PrM 5.1M1
WaterAgricultura Supplyl Well: ittitiMMECIMMii
DIAMETER tl.ta. � _ >r. a '
a icipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. is
Industrial/Commercial ❑Residential Water Supply(shared) -r,--- _ _ .__- —__--_._-- ---___-_---
Irrigation FROM TO MATERIAL EAH'LACEMEHTi ;„&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation , . _ ' I
Aquifer Storage and Recovery OSalinity Barrier FROM Mr EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. fL ":IA` - tJY.t
y Expetimental Technology 0Subsidence Control ft.
Geothermal(Closed Loop) OTracer . .' ` 7'R ''-' . ..t tw a r.., :&. s
s PROM TO DESCRI ION lot, artiness, oTrock type,grain sue,etc)
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �.1 /jam
�y l // 1 pL-
4.Date Well(s)Completed:`)' I / Well ID# lJ`1ft-f S L c2
Sa l Well Location: /`/ D C a tf
S (k;e +f),"�./P// 13a�-k 'i /ky=5 GrO
Facility/Owner Name Facility
ility ID#(if applicable,Z 3
gC7 Nrrc n-107e .A01 tv6oci/F6i {' ft. ft. -
f.
Ph Address,City,and Zip ,„ - ..
< 0 IA/G /2 CCOf , _ ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .,,, —
(if
35well
i field,
�� rag is sicient 40 ( N 80+�_ /_f g � A W 22.Cert1pK# On:
ma's 1----' L�
6.ls(are)the well(s) ermanent or Temporary Si of Certifi�d�vell Contractor Date
By 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 ( with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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 I 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: C (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(41200'and 2@/00) construction to the following:
10.Static water level below top of casing: L/C (ft.) 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: �� (in.) 24b. For Infection 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 construction method: construction to the following:
(i.e.auger,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(gpm) I I Method of test: Air 24c. For Water Supply &Injection Wells: In addition to sending the form to
i the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount: 01/a <L'.PS completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016