GW1--03934_Well Construction - GW1_20240705

WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only. 1111111711
1.Well Contractor Information:
Ricky Corriher -
TO Dt TrnoN
Well Co Name `1� ft. 575—ft. �/� /
AA O [ ,4'(
2464-A ft. ff.
NC Well Cc coon Catintmtion Number - . -_.
-
Frank A.Corriher&Sons Well Drifting, Inc. FROM -TO DIAMETER TT AL MATERI
ft. ft. is
L7I 4 r°mammy Name1 f/�//�
L W Construction Permit if: � ! +-� -PROM
/'—..TO �/ ... DIAMETER n 1 K]CFLv MA17.�IAL
Lai al igpf le well cav'ucton permits(ie.WC,Como,State.Varimroe.etc.) Ai—( ft 5-- ft. 6 VS in' SOR-21 *se
3.Well Use(check well tine): } kt• G el ft. 6 5 /i-Ia. /4,-,i',--
Water Supply well: mtoM T'O c /
._---_.-- -==-D(AMSI'ER---- �;;.oT SITE THTccNFS6
- MATIIIALt
• .- . „,: DM cipal/Public ft. ft. in.
II Geothermal(Heating/Cooing Supply) 8idential Water Supply(single) tt. ft. is.
Residential watea Supply(shertxl) -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
■Irrigation ft_ ft_
Non-Water Supply Weld:
—
II Monitoring °Recovery R ft
Injection Well: ft. ft.
Cnoimdwater Remed1atoa ,,.:. .
f ..: : Recharge - -
U Aquila-Storage amd Recovery DSalinity Barrier FROM TO MATERT.t' EMPLACEMENT METHOD
■ Aquifer Test °Stormwater Drainage ft.
ft.
Subsidence Control ft. ft-
■ExperimentalTechnology •
-___ - .—
Tracer
fa (Closed Loop) FROM TO DES/C��RIPIION(mix.aa+urr4 asaheek type• fie,ate.)
i Geothermal #2 ,�(,
(Heating/Cooling Return) (explain under 1 Remarks) n. ' ) ft- /J'c a 0.) L�)
P4-Date Well(s)Completed: 4-6- well ID# .?[) ft- ,f° ft- G r t 4-1/� i�-�'
5a Location: ` j 2,- G S ft- A-,/Ci',s' t'r, 4.-.k.d --
tCr`i SST c r y GFacility IDir(if applicithle)2 6' ei ft. / z 41.q� G -- ,r_
7.7 r FC;\i J GI,ve4 // / r -
lit i //�Jn/it
ft.
ft.
Address,GUY,a� / ( ✓ /�j llJ�
6i) l4/CA '
Comity Parcel Identification No.(PIN) Tom. .a Ups,,
Sb.Latitude`and longitude in degrees/minates/secondss or decimal degrees: , Sw
f well field,one Int/long is
(35 o / ,2 / sufficient)N 3 7 G' Y 7 y R Z2 / /� n
7 80, /�J D L eM.".. .4 r�1
6.Ware)the wells) P remanent or Temporary
Signature of CaSfied well Contractor Date
By signing this fora.I hereby ca.efy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or 'INClo with 15A NCAC 02C.0100 or/SA NCAC 02C.0200 WeII Construction Stadards and that a
If this is a repo'.fill out know,well aoaarntion information and explain the nature of the copy of this record has been provided to the well owns.
repay raider#2!reesmts section or on the bard of this farm. 23.She diagram or additional well details:
8.For Geeprobe/DPT or Closed-Loop Geothermal Wells having the same YOU may use the back of this page so provide additional wellsite details or well
cotsutxrion,only 1 GW-1 is needed. Indicate 10 1 AL NUMBER of wells On details. You may also attach additional pages if nemcary.
drilled _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I (ft-) 24a. For All Wells: Submit this than within 30 days of completion of well
For ntsetple wells list all depths if different(eranrple-3®200'and 22®1001 construction to the following:
10.Static water level below top of casing: 4 0 (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use`+" - 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: (.• (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Air Drill above,also subunit one copy of this form within 30 days of completion of well
12.Well cons rnetioa method: constrmction to the following:
(i.e.auger,mtary,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
C
13a.Yield(gpm) I 0 Method of test^k 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfectiontype: Sharlene Amount- ea1-2-5 completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina D..F.rtnsart of Environmental Quality-Division of Water Resources k..eived 2-22-2016