GW1--06796_Well Construction - GW1_20241114

Prat Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well`Contractor Information:
Ricky Corriher -145 WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2464-A /25'--rt. l ycit. t254 l
ft. ft. ' i
NC Well Contractor Certification Number 'I5 OUTER•CASII+TG(for'iriiit 1 rsieiI'±ells)'OR LINER.(if in Viable) . '"" `=''
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. ' in.
Company Name t/�� �
16:1NNER EASING"OB TUBING;(geijthermsl:closed loopj:,?;�
2.Well Construction Permit#. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ' l ft. 2 V ft. 6 1/8 in* SDR-21 eve
rI
3.Well Use(check well use): ft. 2 ft. LS l�t'n / / 5 q jv.
l7
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS !MATERIAL
0,,,.. icipal/Public ft. ft m:
• Geothermal(Heating/Cooling Supply) f/esidential Water Supply(single) ft. ft. in.
Industrial/CommercialResidential Water Supply(shared) ;1g,GROUT, + i z
Irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
'....'Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SANDlGRAV.EL,EACK{if.xpplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomrwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.<DRILLING i O.G"(attac[i addiHonal;sheecv feuecessary). _
FROM TO vrioN
F/ DESCRcolor, rdness, oil/rock qpn,grain size,etc.)
Geothermal(Heating/Cooling Return)l Other(explain under#_1 Remarks) �j ft C^O ft, YYYYYY((((((
4.Date Well(s)Completed: '���r �7Well ID# ft. ✓7.Z. ft. S' l oc_
5a.gll Location: i 7 a_ft. 5-4.sic. 6 c,ray tY'�-
tol ley /idol Sale5 ft. ft.
Facility/Owner game !! l Facility ID#(if applicable) ft. ft. I: '..
5-v �my ,g1 /r6i/tvc ✓46 2 b ft. ++- `r _ ...,
ft ft NOV V i F
ysic Address,city,and Zip � / ` ZU[�
Ph
-Ir z�i / ,/ k.7//. � �(Cj REMARKS. , - _ .
County Parcel Identification No.(PIN) f).:, %r';•�;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
(if well field,one la to is tfficicnt)
35 d 0/ j N 80 6 897 �I o ( 22.Certi cation: i
0,-3/-2r
pt
6.Is(are)the well(s) ermanent or Temporary Signature of red Well Contractor Dale
By signing this form, I hereby certifj&that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: Dyes or t o with 15,4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If thtls.is a repair,fill out known well construction information and explain the nature of the copy nfthis 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-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: �� (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@l00) construction to the following:
qo t
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I
•
11.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 form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) l
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air • 24c. For Water Supply&Injection Wells: In addition to sending the form to
1 n Q the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Sterjlene Amount: ✓' ✓ 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