GW1-2022-09592_Well Construction - GW1_20221021

WELL UVINNIRU1 1IIJA KELUKU(UW-1) For Intemal Use Only
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name EOM TO DESCRIPTION
R
2464-A
fL
NC Well Contractor Certification Number
Frank A. Corriher&Sons Well Drilling, Inc. ��FROM TO I DrAMETM TMCKNIM MATERrnL
& fL in.
Company Name
2.Well Construction Permit# (/� /J o PROM TO DLAMETER TffiCfavBss M,,,r$Ripr
List all applicable weU construction permits(`Le.UIG County,State,Varix=etc.) +1 f ` ft 6 1/8 in SD R-21 PVC
3.Well Use(check well use): clr
Water Supply Well: FROM To DIAMEfE$ SLOT SIZB TffiCSNTLSS MATERIAL
❑Agriculttual ;Z'd.,ipal/Publi. ft. ft. ! in.❑Geothermal(Heating/Cooling Supply) tin)Water Supply(single) fL fL in.
Olndustrial/Commer-cial ❑Residential Water Supply(shared)
❑hri -on ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METaOD&AMOUNT
Non-Water Supply Well: 0 fti 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery tL fL
Injection Well:
R ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FttoM To MATERML EMIT C3MErrrbWM0D
❑Aquifer Teat ❑Smrmwater Drainage fL fL
❑Experimental Tecbnology, ❑Subsidence Control % fL
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Coolin Return) (❑Other(explain under#21 Remarks) FROM fftL T��O77 D ON r reck eee
a� G� f
4.Dace Welt(s)Completed• D Well ID# M 2 ft
52.Well Location: / / _ �ft �Of R �
L✓Gl6 �'j�12 ��/4t /, t� fL fL .r t.- f
Facility/ Name �y ID#(ifapp�le) fL ft
Physical Ad ,and Zip ft. fL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.C ca
35 ' /�" N 800 —��'— 9 W
of ed Well Contractor 6.Is(are)the weIl(s): ermanent or ❑Temporary Sigoatme Date
By signing this form,)hereby certify10-the-U(s)was(were)constructed m accordw,,wink
7.Is this a repair to an existing well-. ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f this is a repair,fdl out known well construction information and explain the nature of the of this record has been provided to the well ow w
repair undo#21 remarla section or on the back ofthisform. 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 wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24-SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: _
For multiple welb list aU depths if&ffoeu(example-3Qa 200'aand 2(a)10V) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: pC� (fL) 24a. For All Wells- Original•form to Division of Water Resources (DWR),
lfwzw level is above casing,use + Information Processing Unit,16 17.MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method: 24c.For Water Supply and O�
(Le 'row'cable,direct push
en-Loop Geothermal Return Wells Copy to the
etc) 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
(BP ) Method of test:13a.Yield m Air Permit Program 1611 MSC,Ralergb,NC 27699-1611
13b.Disinfection type: Sterllene Amount: C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resodrees Revised 6-6-2018
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