GW1--05407_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FR M TO DESCRIPTION
2464-A
NC Well Contractor Certification Number �Q ft' ,, ft'
Frank A. Corriher&Sons Well Drilling, Inc. FROM �TO 'DIAMETER THICKNESS MATERIAL
r�' -i /'mil ft, is
Company Name / Q /i
2.Well f Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) '' ft• 3 5 ft• 61/6 in' SDR-21 we
El3.Well Use(check well use): ft- ft is ? Z/
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 4ai
cipal/Publicft. ft. in.
Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft. in.
Industrial/Commercial E3Residential Water Supply(shared) ,.r ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft.
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge DGroundwater Remediation
.
Aquifer Storage and Recovery 0 Salinity Barrier •O O MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) 0Tracer "- ' �- '� ''"` _ _ se`. _ _A.it: - _
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO D RIPTION(on arda savroek type,grain size,teal
4.Date Wells)Completed: " q Well ID# Q ft. 35 ft- S . 4 O c
J' a pi .. Y��' ft* ft. l // /�n t'`
Se.Well Locptio� �� 1 � �j/L>! e (jam CL_/j�. -
Om fi i/(S�m e4 5 fL .. i.j
Facility/Owner Name , Facility ID#(if app icable)) / / ft �p - �`/ t.•La
ly0 el/2eZ ./1fve rs�lif ft.
SEP99202E
Physical Address,City,and Zip
o lvot 4 3 ao,�c 70 .�_,. — _—..� .�a _ , s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(35 iif t field, >�t/long is su tent)N $O �Fg i�) W 22.Certi lion:
GO qw -
6.11(are)the well(s) ermanent or DTemporary Sign of C Well Contra for Date
dor
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or o with I SA NCAC 02C.0100 or 15A 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#21 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-1 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: / 6 (ft) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2�@100') construction to the following:
10.Static water level below top of casing: 3`•' (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 Inflection 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) 9. Method of test: Air 24c.For Water Supply&lniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount: Q< C r 5 completion of well construction to the county health department of the county
/ where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016