GW1--06501_Well Construction - GW1_20241101

r P rni Form`` 1
WELL CONSTRUCTION RECORD (GW-1) • . For Internal,Use Only:
1.Well Contractor Information: '
i
Ricky Corriher
I4:wATERzoNEs 1,a .,.w .L.. , zA.-.n.. ;,
Well Contractor Name FROM TO ULSCRIP rION
2464-A ft .22 Shd //
�k ft, 1• tD 61 cy/
NC Well Contractor Certification Number t
n'.IS.OUTER t?AS11YG(for multi cased.'wells)O LINER(if:a_ Ifeable). -
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER I THICKNESS I MATERIAL
I
Company Name ft. ft. tn.
/_ Q' A6.INNER CASING:OR 1'UBING.(Reot&ecmal-clbsed loop),yr;a :, :,`
2.Well Construction Permit#: I)OQ 9O FRO 1 TO DIAMETER . THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance,etc.) .1—) ft. ) / ft. 6 1/8 I in' SDR-21 Fvc
3.Well'Use(check well use): /b/ft. /43 ft. c' 57. / / a I6/ ,
Water Supply Well: `-.'SCREEN "` __ ..,3 : O o .-,J Q,
A rICDItUral FROM TO s DIAMETER SLOT SIZE THICKNESS - MATERIAL -
g 0 j/tcipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ) Residential Water Supply(single) ft. ft. in. .
Industrial/Commercial Residential Water Supply(shared) Ig,GROi3 f
Irrigation FROM TO .-MATERIAL EMPLACEMENT METHIOD&AMOUNT
=
Non-Water Supply Well: ft. ft.. i =' .-
Monitoring Recovery ft. ft. ' jK•� aid
injection Well: _ ft.• ft. NOV 0 1 ZUL4
Aquifer Recharge • 0Groundwater Remediation
19r,SAND/GRAVEL TACK(if,applicable} ;{: :.
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL Ir 1PtACEMENTtMETEIOD ,z
Aquifer Test EggStormwater Drainage ft. ft. •,•
Experimental Technology EDSubsidence Control . ft. ft. .
Geothermal(Closed Loop) OTracer 20:DRILLING'I:oG:(attach additlonilsbeets'if`uecessary),,-
Geothermal(Heating/Cooling Return) Other(explain under#2l Remarks) FROM TO DESCRIPTION(e tor,hardness,soil/rock type,grain size,etc.)
q /� /, ft. �d ft. 3,i/
4.Date Well(s)Completed:' -- /-tl r.g.%Nell ID# 440 ft., ' $ D ft. (`. rli• ,
5a.Well Location: - , i'--1. f.' 10,3..ft• •S� r ekite. _1L
``�� r ft.,. rft... . 2,e• �dn
S��i1,C� / � 0d� � �'�� SAS .�.
Facility/ow,.Nan(e -- .; ft. ft.
Facility ID#(if applicably / �
I/�f7 t r / '.� r sz% ( ft. •ft.
Physical Address,City,and Zip ft ft
ci
ito f/(/ 3� Y Y 2- 9efl1::REMARKS-. , t 1:;-fa . . > . . ._... , ._,r
County Parcel Identification No.(PIN)1
5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22.Certification
350�h?c9Q 7 N 80, gi-,� q W ( �Q �'„,/,' -/�=
6.Is(are)the well(s) ermanent or Temporary
Signssur�Cenirreo Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Ire' o with 15A NCAC 02C.0100 or 15.9 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair./Ill 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:
Youmay 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: (5`62_5.- (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 10 the following: �� ' P
10.Static water level below top of casing: ytJ (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•4-"
1617 Mail Service Center,Raleigh,NC 27699-1617
�- I.
i1.Borehole diameter.-_. . (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 fonnwithin 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
Air i
Q
13a.Yield(gpm) V g'• Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
t`LF the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterilene • Amount: completion of well construction to the countyI health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016