GW1--04116_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Ricky Corriher _ _-- - -—.
FROM TO -DESCRIPTION
Well Contractor Name /��c-R. /7 f n 47 ,, t:/
2464-A d 3)r Lie (./
�.
NC Well Contractor Certification Nmnbe — --
Frank A.Corriher&Sons Well Drilling, Inc. FROM TO D' ►T`'� T' SS M-"ERIAL
rr ft. ft.
Company Nye Zid
L/ V �t� 9 _ -- --
2.well Consandiea Per wit#: � T/O fthew=R TRICK stierm m,
List all aIyMe.hle well c nstr a tion peanut f UIG County.State.Variance.etc.) ` l ft- 6 l R' s U8 pa.M. SCR-21 o c
3.Well Use(cheek well ttse): S 7 ft. ' f, 5 - c 1.(L/
Water Supply WeR: FROM TO DIAMETRIC( SLAT sat TlnotnEss MATtatIAl.
• . o,. ■ . «.. .fin ft. ft. in. -
%.,
■Geothermal(Hi-wine/Cooling Supply) • Residential Water Supply(single) ft. ft. Ia.
a °Resid ntial Water Supply(shared)
—PROM TO MATERIAL ------TD(PtAiiAthM'METHODaAMO(7NT
■irrigation ft. ft
Non-Water Supply Well:
I MonitoringaMonitoring [#I(xav«y ft. ft. 1 L.1.• V E ")
Injection Well: ft. ft. ,,
■ Recharge [J
SC,rotmdwater Rernediarim . — • --- ?
■Aquifer Storage and Recovery DSalinity Barrier FROM To MATI3RIAI. _tMIP Acz MINT METHOD
f. R
a Aquifer Test DStormwater Drainage —
■ExperimentalTechnology °Subsidence Control ft. ft.
•• _.,,- (Closed Loop) DTracer _ �.,
-PROM TO _ ; rat.*hre..ta++a ass.etc.)
■Geothermal(lieatingfCooliagReaun) [��lt�(explain under#21 Remarks) �`Ld Pdj�
4.Date Well(s)Completed� / Well `�() (� n 554. --
er. rt.
�. / f2/1So/2 17 7) /EL Facility IDS cif a >s
ra7Tvi'xieroo / / ril 'e7'Giese/' 1ti,/ ,,c.
/91akA�rS - _-
Coway Parcel Identifcation No.(PIN)
—
Sb I atitaade and longitude In degrees/mmates/seconds or decimal degrees: .
(if ,So is sufficient)
)N f 7 � 22 4 /
-,27
Si ne of e�C e� Date
6.Ware)the weil(a P rerinaneizt or °Temporary
By ng�g this Iona,I kerebv ce.tif}-that hie wdl(s)was(were)constructed is accordance
7.Is this a repair In an existing well Yes or o with 1 SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Weil GmsD action Standards mid that u
If this is a repair.fill out knows well construction Ialwmasioe and explain the nature of the COPY of this record has been providd to the well owner.
repair under ii2 I remarks sexton 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 I OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nerwcary.
dnllled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 (ft-) 24a. For All Wells: Submit. this fined within 30 days of completion of well
Far multiple wells list all depths if different(example-Ira 00'and 22@100') construction to the following:
10.Static water level below top of casing: l, (ft-) Division of Water Resources,Information Processing Unit,
If,aater lend is abuse casing,use,.+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: li (in.) 24b.For laiecttou 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 onintrn ctiea lugelesd: construction tion to the following:
(i..e_auger,rotary,cable,direct push,etc.) -
Division of Water Resources,Underground Injection Central Program,
FOR WATER SUPPLY rS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Art 24c.For Water Supoty&Infection We In addition to ceding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Di ation type: Sharlene AmountC.C{ 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