GW1-2022-01212_Well Construction - GW1_20220103

y __.I LY a aw. a avl.alarm vxu For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPI[ON
2464-A it � d� ,
NC Well Contractor Certification Number ft_
f
Frank A. Corriher& Sons Well Drilling, Inc. FROM DIAMETER t fps
Company Name
Z n• in.
2.Well Construction Permit#: �.J �/ FRoin ro nI,►MEr,R THIcxivEssT
List all applicable wall construction permits(1.e.UIC,County,State,Variance,etc.) +1 ft' ` ft• 6 V8 1n
SDR-21 PVC
3.Well Use(check well use): D 1 ft. ft, v
Water Supply Well: C �'✓
❑ culttural FROM 7'O DIAMETER SLOT SIZE THICKNESS MATERIAL
�— ❑ cipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) kfesidential Water Supply(single)
_) ft. ft in
6 ❑Industrial/Commereml ❑Residential Water Supply(shared) _
❑lrri 'on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOrrNT�v Non-Water Supply Well- 0 22 iL Bentonite Hole Plug
rOAquifer
ring ❑Recovery ft. ft-
Injection Well:
Recharge ❑Groundwater Remediation M tt
Storage and Recovery ❑Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology []Subsidence Control ft. ft.
❑(3eothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRn7ION eoror,hardness,-Wreck »ram�)
fL ft
r
4.Date Well(s)Completed: Lid ft. a ft. sr_" I✓
Sa Well Location: n/^ 9! IL 163 ft•
ft-
Facility/Owner On�GName) Facility ID#(if applicable) ft. ft
420
Phys ddtess,City,and zip C i� ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �[
(if well field,one lat/long is sufficient) 22.C cation:
35 0 3 `7 3 /'� N 80 0 -3 7
w �/� f
6.Is(are)the well(s): �permanent or ❑Temporary Sigaattae of ed ell Contractor Date
AV signing thisform,I
(Were)constru
7.Is this a repair 1b an existing well ❑Yes or 15A NCAC 02C.0100 or ISA CACeby carrify t 02C-0200hat the 1(Well lCConstruction S ctmtdar,&and that a copv
Ifth s is a repay,fill out,Mown well construction information and explain the nature of the - of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wa
drilled: lls ( Over in Remarks Box).You mnay also attach additional Pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ (J' O
For multiple wells list alldepths ifdifferent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion p per the following:
10.Static water level below bop of casing: (/ ( ) 24a• For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. sir (in) 24b.For Iniection Wells: Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
(i-e.auger,rotary,cable,direct push,etc,) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county envmronmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wets Droducin¢over 100 000 GPD Copy to DWR CCPCUA
13a Yield Wm) e+3 Method of test:AI r Pemmt Program.1611 MSC,Raleigh,NC 27699_1611
13b.Disinfection type: Sterllene Amount: r✓a S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018