GW1--06850_Well Construction - GW1_20241115

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WELL CONSTRUCTION RECORD (G —I) Pt' I' ° '-. `'
For internal Use Only: "'�
�V
1.Well Contractor Information: f
Ricky Corriher
I .14.WATER ZONES- '. „ I
Well Contractor Name I FROM TO DESCRIPTION
116-"0 ft.1 tt_ ft, Vs,I ;Ca/
' / s-ft, /�! I Y5 a/
NC Well Contractor Certification Number t
1 OUTER•CASING'(itir mutts=caied.teells)•oR"LINER(if applicable)__'Frank A. Corriher&Sons.Well Drilling, Inc. FROM TO DIAMETER , I THICKNESS MATERIAL
Company Name
` ft, ft. in. 1 �.
00 �_7 16.1NNERCASIL G OR TUBING.(geothermal:closed-loop) •
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MAMMAL
List all applicable eel!construction permits(i.e.U/C,Cousin•.State.Pm-lance,etc.) ' ' I—)) ft• P-g---. it- I 6 1/8 I' in.
� SDR-21 eve
ki 3.Well Use(check well use): Agri' 3 r) ft. 1 t�/ qk'r,t- 1 8 • Q rv.
Water Supply Well: 17:SCREEN: I I
V FROM TO I DIAMETER I SLO'rsuw THICKNESS MATERIAI.
Agricultural DN unicipal/Public ft. ft. in.
Geothermal(Heating;Cooling Supply) csidcntial Water Supply(single)
ft. I ft. in.
'industrial/Commercial EiResidential Water Supply(shared) '
•irricatio❑ FROM' 1 TO MATERIAL. I ( EMPLACEMENT METHOD 3c AMOUNT
. Non-Water Supply Well: ft. ft. I,
Monitoring ®Recovery ft. ft.
Injection Well:
Aquifer Recharge ft. ft. 1
QGroundwater Remediation
,Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(if applicable) '- -
QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ^
Aquifer Test' . DStonnwatcr Drainage ft. ft. .
I `
Experimental Technology 0 Subsidence Control ft. ft. I
Geothermal(Closed Loop) DTracer 20.DRILLING:L•OG(attsch;additional.sheet§it.necessary -_ •
FROM I TO DESCRIPTION(color.hardness.soil/rack type,grain size.etc.)
Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks)
0 ft, ad ft. /5/ 1 iv— 10•
4.Date Well(s)Completed:/1 9 �/2 j Well ID# I ft. 1v ft. p e.J l ep 'J (A( d n`vr.)yL
•Sa.Well Loins•on: nn ry J fL' •) ft. /l /1 J G7I
of'dGdl l�q . Cp/j') ft- Zift, plat. inlC Qrcw,,r £ /(-
Facility/Owner Name ,Q Facility IDn(if applicable)6-701
(j '� v ft. ft.
��� c LAC/��'li��r'/l C �a 13e ft. ft. i. .
Physical.Address,CCiity, n Z p _ ft. ft. 1 `�r� •� y
Ggtb.o, ( r po - 21.,REMARKS NOV.1. 6024 ..
"l. aC. r�
County Parcel Identification No.(PIN) ' ,
e
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I C` E,;' e';y y
(ifwell field o lavlong is sufficient) 1� 22.Certif ation:. 1 j
41
rt�1_z: /i t • l� e- -.,
6.is(are)the well er s) manent or Temporary Signature or Cc�Well Contractor Date
iir signing the:,/itrat. 1 herrhr(-erg i'that thr we-11(st was(were)constructed in acc•rn'rlatcc
7.is this a repair to an existing well: Dyes or •o ,lith l5A A'C:ICO2C.0100 or 15.4.VC.aC 02C.0200(fell Construction Standards and that a
!phis is a repair.Jill out known well construction it frrnmtian and explain the nature of the ,upr Of-this rrrurd has been provided to the well nrcrice
repair under#2/remarkssection or on the back oft/dsJornt. .
23.Site diagram or additional well details: '
You may use the back of this page to provide additional well-site details or well
3.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:
o� SUBMITTAL INSTRUCTIONS I,
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 iifdi jji•rent(example-3ru.?110'and tft/00') l
n construction to the Following:•
• 10.Static water level below top of casing: `� (ft.) Division of Water Resources,llnforination Processing Unit,
rer level is ubore easing,use 1617 Mail Service Center
If„ra ,Raleigh,NC 27699-1617
11.Borehole diameter: GO in.) .24h. For Injection Wells: In additioIn to sending the font to the address in 24a
Air Drill above. also submit one copy of this ioritl-within 30 days of completion of well
12.Well construction method: construction to the following: `
(i.e.auger.rotary,cable.direct push.etc.) e
Division of Water Resources.Un erground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) Z' 5 Method of test: Air 24c. For Water Supply&lniection','Wells: In addition to sending the form to
Sterilene
l the address(es) above, also submit one copy of this form within 30 days of
/-
13b.Disinfection type: Amount: a GGrc . completion of well construction to the;county health department of the county
where constructed. I i
Form GW-I Nonh Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
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