GW1--05802_Well Construction - GW1_20240926

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WELL CONSTRUCTION RECORD (CV%-l) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher 14.WATER ZONES
Well Contractor Name FRO NI 'IT) DESCRIPTIONS
2464-A t� /7 4`ft. o� 6-Q /
(` t fit. Frei NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a ticable)
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
2.Well Construction Permit#: oO O 9 9 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County,State, Variance,etc.) -t.I ft. 9S ft. 6 1/6 in. SDR-21 PVC
3.Well Use(check well use): if5 ft. 4/
`T 7ft. 6 in. t g g Q 0c LY
Water Supply Well: 17.SCREEN
FROM 10 DIAMETER SLOT SIZE 'I HICKNESS MATF:RIAI.
Agricultural nicipal/Public P al/Public
ft. ft. in.
DGeothermal(Heating/Cooling Supply) Residential Water Supply(single) I ft. ft. in.
1
°Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
°Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
()Monitoring DRecovery ft. ft.
t)p Injection Well: ft. ft. -
Aquifer Recharge Groundwater Remediation _I
Aquifer Storage and Recovery ��{{Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
IJ ty FROM TO MATERIAL I EMPLACEMENT METHOD
E. DAquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
QGeothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ©Other(explain under#21 Remarks) FROM 1'o fESC IPIION to hard es.soil/rock type,grain sire,etc.)
0 ft. al ft. Xe , `;'
4.Date Well(s)Completed -29Weii1D# aQ ft. 3a ft. C'�a . y 1
5a.Well L anon: 30, ft. 37 ft. J�^aj)/ .T
BOAn C h fn tom, ?7 ft- 7 ft. Keck fecK _
Facilit/Uwnc Namc F cility ID#(ifapplicable)r e / ! /ft. t. 6-
. /-'__ _I i e
g3 3 0 6 /d/tif id%�f i�// ���ttttltt`�ft. r-.C3, 'Gf.
Physical A dress,City,and Zip ft. ft. a `' 1...L d
e. A/7( 21.REMARKS SEP 2 U 7024
County Parcel Identification No.(PIN) J
IfifS:':::4.Lf i ,3,,-.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ Q•:'� I I
llik
(if well field,one lavlong is sufficient G'� 22.Certif 'on: b•�s t.r t3;y
35f `'f 4 q 80, 3390 1 7 W /J,,,,,,6 _29^.9
6.Is(are)the well(s) ermanent or Temporary Signs urc of Certi ell Contractor Date
By signing this farm, 1 hereby certi/v that the wells)was(wen)constructed in accordance
7.Is this a repair to an existing well: Yes or o with 15,4 NCA('02C.0100 sr 15,4 NCAC 02C.0200 hell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature oldie copy of this record has been provided to the well owner.
repair under#2!remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I 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: V- (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@200'and 2@100') construction to the following:
10.Static water level below top of casing: 4 O (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
12.Well construction method:
Air Drill above,also submit one copy of this form within 30 days of completion of well
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) a Method of test: Air 24c. For Water Supply & Iniection Wells: In addition to sending the form to
�/pZ cps the addresses) above, also submit one copyty of this form within 30 days otf
I3b.Disinfection type: Sterilene Amount: / completion of well construction to the coun health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016