GW1--05662_Well Construction - GW1_20240920

WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only: '
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1.Well Contractor Information:
Ricky Corriher f . . e- ,.-'. t. _
FROM TO DESCRIPTION
Well Contractor Name tl pcit• a /3 r� Q(
2464-A • ft. ft. i
NC Well Contractor Certification Number
Frank A.Corriher&Sons Well Drilling, Inc. •
FROM TO DIAMETER, THICKNESS MATERIAL
ft. ft ' in
Company Name ` 7 ' t/1 n - ."iititased-lbtrl` r°B* 's`.
2.Well Construction Permit#: (// si., �/ FROM . TO DIAMETER THICKNESS. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) . l ft 6 ft. 61/8 in* SDR-21 pvc
0 ft /(t7 z_ ft. _V.V"in. $iB p/l/
3.Well Use'(check well use): ?j d
i i -..7 .: .s ,.517Zi.g a.�.c..,.^Ys+.3agtita t.«fita:.S ' esPM70a a?
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultlrral . 0 ,, 'cipal/Public ft. ft. in;
Geothermal(Heating/Cooling Supply) e!.''esidential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared) y x,-me , �,F ,.-74-
'gation • FROM TO :MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring °Recovery - ft- ft. •
Injection Well: ft. ft
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery C3Salinity Barrier . FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStbrmwater Drainage ft ft ,
Experimental Technology OSubsidence Control ft.• ft.
Geothermal(Closed Loop) OTracer . i#L tf cr4uttse>is d dleria a et ;`*it` ;e w.
FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. ye9 ft. .a� .., 0 a d--
4.Date Well(s)Completed:F l/r,ef Well ID# L1( ft. /2 ft. S L(L` D ��Y
sa.w u L don:/1,Q i/c�? i 6k• •Q . 6) ft (ram Z IL. SO•-J-- a-c c-IL •
Facility/Owner Name �iA
/ Facility ID#`(if applicable)(1 ,�/J f. ft. .,t. — *`:'f t
&cQOj / ! t V G� T t� ft ft • ' f l� j.e
Cl-Call 5 cLJ Ne i :.
• Physical Address,City,and Zip f. ft. J`i� 2 0 L U 24
d'14_ Q IrSv.rr.,;ett e!,
County Parcel Identification No.(PIN) d 0 Jr?:
D....e vtt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,
(if well�1�one lat/long is Sufficient)N $O � � © w 22.Ce tion:
cf2 7 G ,—//Gqy
6.Is(are)the well(s) Permanent or Temporary Signature of C '' ed Well Contractor
7.Is this a repair to an existing well: ®Yes Date
By signing this form.I hereby cerl fy that the well(s)was(were)constructed in accordance
or with 1SA NCAC_02C.0100 or ISANCAC 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 fonts.
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.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ( ( ' (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3Q200'•and 2(a 100') construction to the following: i
10.Static water level below top of casing: /J 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: ( .(in.) 24b.For Iniection 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 SUPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /3r 5/ Method of test:Air 24c.For Water Supply-&Iniection Wells: In addition to sending the form to
. the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Sterilene Amount: 0 Cd�s completion of well construction to the county health department of the county
• where constructed. i '
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources ' - Revised 2-22-2016
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