GW1--06797_Well Construction - GW1_20241114

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Ricky Corriher
. 14.'WATERZONES''„I._. .`•:..-j'r -
Well Contractor Name FROM TOI DESCRIPTION
2464-A /,flat. 40 ft. ' 19 a
• ft. ft.
NC Well Contractor Certification Number i
`15 OU7'ERCASING,Iforiiiiii*eased rr:ILeIDR,L;INER(if'.a--usable):.. _
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name ��
16:IN,'VERCelS1N.G'ORTUBWG:{geofhertnsl:dosed-loop7,,., ,
2.Well Construction Permit#: _3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.c.Ii1C.County,State.Variance.etc.) }/ ft. 6 6- it. 6 1/8 ! 'in' SOH-21' rvc .
3.Well Use(check well use): /„ Crft. 7d ft. /r_}r�/:
In. /gr.
�j 3 C 1i
Water Soppy Well 17.SCREEN ... tO_ ../_OD
FROM 'r0 -•DIMIETER SLOT SIZE: 'THICKNESS SIATERIAt.Agricultural OM icipaliPublic ft. ft. in:
Geothermal(Heating,'Cooling Supply) esidential Water Supply(single)
ft. ft. in" .
'Industrial./Commercial • Residential Water Supply(shared)
'Irrigation FROM TO t 1 MMATERD,U EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. I' '
Monitoring ®Recovery ft. ft.
Injection Well:
Aquifer Recharge ft• i ft. I I
9 OGroundwatcr Repudiation
Storage and Recovery •19.SAND/GRAVELPACK(if applicable) -
Aquifer
..
g D Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test QStonnwater Drainage ft. ft. I
Experimental Technology 0 Subsidence Control ft. I ft- I I,
Geothermal(Closed Loop) Tracer y)
20:DRILLING LOG;fattacb uddtdonal:sheets•ifnecessat
FROM TO DESCRIPTION(color,hardness.soil/rockhpe.grain size,etc.)
Geothermal(Heating/Cooling Return) Li Other(explain under Remarks)
�y 4 ft. 3-0Q fi4A
b t
4.Date Well(s)Completed:w ( _
� 9 YWell ID# 3Q ft. b 0 ft. y
5a.We I Location:/ j� �+ / C /! fL. 7v ft. . /1 ,Gj r) 6,
I-! / J 04 e iG es 9 cv t�ft. �r t}d— d`CAL
Facility!Usvner Facility 1D'(if applicahlc)�U ���I ft, ft. ����
r .°incp�N'y Rd /( /i a4 lye � _ ._.�y ; . ,
Physical Address, /7 City.and Zip � ft. ft.
:Y:ree// . 7%f/ I3-,(4i2?ARKs .t;..,_ ; ... _ NOV I LOZ'l . .
County Parcel Identification No.(PiN) ! ' t_".'.^.. a r'Y.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: G7: t,c. `-"3
(if well field.one laulong is sufficient)
rr 22.Ccrti ation:
35 c Q 6 so, N 80 t 3 7 / V/} y w • , I,a o�q oG" -
6.Is(are)the well(s) ermanent or Temporary Si_ tore ofC tcd Well Contractor Date
By.signing thd-irrm. /hereby cent&i'that the ac•i/(.si was(were)constructed in accordance
7.Is this a repair to an existing well: ®yes or o with/5.a NCIC 02C.0/00 or 15.4 NC.•IC 02C'.0200 Del Gansu c'tion Standards and that a
if this is a repair.fill out known reell construction information and explain the nature afthe gl?t'of this to turd has been provided to the well owner
repair under'42/remarks section or on the hack al'this Jim.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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: �j SUBMITTAL INSTRUCTIONS i,
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9.Total well depth below land surface: 3 a (ft.) i
24a. For All Wells: Submit this lfornt within 30 days of completion of well
For multiple wells list all depths fd fJrrent(example--i@200•and 2 a!l00't construction to the following:
•
go
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
(inter level is above erasing,arc "rn 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: b/ (in.) 24h. For Injection Wells: In addition to sending the form to the address in 24a
Air Drill above. also submit one copy of thi form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary,cable,direct push.etc.)
i
Division of Water Resources.Lnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I
1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield'(gpm) a. Method of test: Air 24c. For Water Supply& Injection Wells: In addition to sending the form to
Sterilene
3 C.q�S •the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed. •I
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Fonn CiW-I North Carolina Department or Environmental Quality-Division of Water Resources t ! Revised 2-22-20I6
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