GW1--05414_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher a-.. .: .. ..... _::: .:,.,z . _ 5-I.. .- a:'_v2 ,:: -,,,
FROM TO DESCRIPTION Well Contractor Name /
ft. 6o ft. ,c to
2464-A
ft. 1 bet- i ;-a
NC Well Contractor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. FROM TODIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ,/) ___ -O -.._. _ DIAMETER
R'77,_ _H _. 7 _.
6'all '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permi (i.e.UIC,County,State.Variance,etc.) . I ft. 3s-fL 6 118 to SDR-21 eve
3.Well Use(check well use): 3-ft. - ft. 5 in. /5 r lG,
Water Supply Well: FROM TO DIAMETER SLOT SIZE � MATERIAL
Agricultural icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) , ,t ,,?, ,4- s.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring ORecovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge 0Groundwater Remediation
`
Aquifer Storage and Recovery Ei Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft' ft'
Experimental Technology IDSubsidence Control ft- ft-
,_.-. _;_ ,� . . am;..
Geothermal(Closed Loop) Tracer -. .. . _.. _ z-�= ..
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To nest ION color,earthmen,aoivrock type,gran size,etc.)
© � QO � of / air 74
4.Date Well(s)Completed. y Well ID# �)Q ft ft , D -f Re .CS.--:‘
./e
ft f�
5a.Well Location: 3a ��� f�r/�L e ��'QA//
r fL ft. r�
Qn'11raQlves4mr -
Facility/Owner Name Facility ID# if a licabre�4/9q v- L.1`- vJ I—>v
13a /I z-a ,� "'e Sqi pll 77 ft. ft. SEP 0 S 2024
Ph 'cal Address,City,and Zip ft- .-. - .._ . .. .
a>,.0 3d# Gq .._ ;•
County Parcel Identification No.(PIN) #tit
a
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,o I lat./long is sufficient) //p Q / 22.Ce • • n: n
35
N
6.Is(are)the well(s) rmanent or Temporary Signature of Certifwd well Contractor Date
By signing this form,1 hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O Yes or No with I5A 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#2l 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.
dolled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /!O S (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@20`0'and 22@100) construction to the following:
10.Static water level below top of casing: ..I 0 (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: b (in.) 24b.For Injection 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) 13 Method of test: Air 24c.For Water SuDnly&Injection Wells: In addition to sending the form to
/� / C/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene Amount: !X.a C5 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
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