GW1-2022-08398_Well Construction - GW1_20220829

r.xra..i,%-Un a I AU 1U1.V KLUUKD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIPTION
2464-A ye'01L 1-/6Qt
ft It.
NC Well Contractor Certification Number
Frank A. Corrlher& Sons Well Drilling, Inc. FROM ft ft TO DrAME7ER TM MATERL►r
�j in
Company Name .c J �/���
2.Well Construction Permit# FROM TO DIAMETER Tmcxnss MATERIAL
List all aMlicableweA construction permits(z.e.UIC,County State,Variance,etc.) +1 fL ft 6 /8 1° SDR-21 PVC
3.Well Use(check well use): ft ft tn. f v
Water Supply Well: ,
FROM TO DIAMETF,R SLOT SIZE TffiCIQVESS MpTERL1L
❑Agricultural ❑ 'cipaUPublic ft ft in
❑Geothermal(Heating/Cooling Supply) l Residential Water Supply(single) ft ft in.
❑IndustriaUCommercial ❑Residential Water Supply(shared)
Olhigation ❑Wells>100.000 GPD FROM TO MATERIAL EMPI ACEMENT ME-rHOD&gMouNT
Non-Water Supply Well: O ft. 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft &
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediati on ft t
_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EM LACEMENr METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer - -_
ma
❑Geothemmal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION eoro.hardness soiYroetc et-)
/�f fLro ks kV
4.Date Well(s)Completed: --/ / Well ID# rt Q ft
sra.Wp"'Ir,oGa%on: ft ft
-ell ft Q ft 2 V
FaciH.. ?weer r Fac'' # ' applicable ft ftft. fL
Phys' Address,City,and Zip ft ft ;�`� +
Ll)qF �. tot
Cow Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latilong is sufficient)
35c/.-('2 j/ or" N 80 ^ �32 7 � /I 22.VCecatio /
(J w
6.ls(are)the weU(s): ermanent or ❑Temporary Signature of@ rtified We Contractor Date
By signing this form,l herebv certijv that the"11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or � 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis farm.
23.Site diagram or additional well details:
8.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 wells (add'See Over'in Remarks Box).You may also attach additional drilled: P if necessary.
�� UBMITTA
9.Total well depth below land surface: 24.S L INSTRUCTIONS
(�)
For multiple wells list all depths ifdifferent(example-3Q20�d 00) Submit this GW-1 within 30 days of well completion
p per the following:
10.Static water level below top of casing: (ft) 24a• For All Wells: Original form to Division of Water Resources (DA R),
If wags level is above caring,use'•+• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (11•) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Proms,1636 MSC,Raleigh,NC 27699-1636
(i e.auger,rotary,cable,direct push,eta) 24c For Water Snlmply and Open-)Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producing over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
136.Disinfection type: Sterilene Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6_2018