GW1-2022-10542_Well Construction - GW1_20221118

WELL CONN'1'KU UTIUN KLUUKU(ti W-1) For Internal Use Only.
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name ft. 63L tZl �l
2464-A ft. fL
NC Well Contractor Certification Number -
Frank A. Corriher&Sons Well Drilling, Inca FROM TO uIAME-rER 7111cKlam MATS
rt fL ;a
Company Nam g� - - -
2.Well Construction Permit#:Q� (7i✓r _ I �8 � FROM TO DIAMETER THICKNFss MATERIAL
List all applicable well construction permits(Le.(TIC.County,State,Variance.eta) +1 ffi 72 fL 6118 in SDR-21 PVC
3.Well Use(check well we):
77ft- 79 >t
Water Supply Well: FROMI TO DIAMETER SLoTs= THICBNfy48 MATERIAL
❑Agricultura1 ❑ ' i t.Mblic ft ft. in.
❑Geothermal(Heating/Cooling Supply) idea W Water supply(single) ft ft in
❑ladustrial/Commereial OR esidential Water Supply(shared)
❑hri 'on ❑Wells>100,000 GPD 70 MATERIAL EMLACEtYIEnMErHOD&AMOUNT
Non-Water Supply Well: 0 "' 22 Bentonite Hole Plug
❑Monitoring []Recovery ft. fL
Injection Well: ft M
❑,Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACBM M METHOD
❑Aquifer Test ❑Stormwater Drainage ft I fL
❑Experimental Technology ❑Subsidence Control it ft.
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReiurn) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION r bmdnea�s.Wrxk size,etr-
r 1 fL /j fL
4.Date Well(s)Completed: `r 1 �- Well ID# q10 fL L('"L
5a.Well Location: --2 0 fL 7 ft S,/r(9
Sr.`l'y L.�X N L / � A5 , �'d,� � '
Facility/Owner Name Facility 1D#(if applicable)
ft ft.
it ft. UrA
nov
County Parcel Identifiu ation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Ing is sufficient) f/ 22.C catio
35©3�rat/lo 35)" N 800 ` qq0 W nn
6.Is(are)the well(s): or ❑Temporary Signature of Cghffied Well Contractor Dare
Bvsigning thisform,I herebv certify that the wells)was(were)constructed to accordance with
7.Is this a repair to an existing well: ❑Yes or 4. 15A NCAC 02C A100 or ISA NCAC 02C.0200 Well Construction Standards and That a cop„
If this is a repafr,fH out known well consavcdon information and explain the nature of the of this record has been provided to the well owner.
repair under#21 romans section or on the back of thisform. 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well contraction info
construction,only 1 GW 1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
dolled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) Submit this GW-1 within 30 days of well co letion r the folio
For multiple wells list all depths tfd{$erent(example-3@200'and 2Q100) Y� rap per wing.
3 (fL)
)ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
if inter level is above casin&use Static water level below tap of casing: Information Processing Uni%1617 MSC,Raleigh,NC 27699-1617
!f ••+'•
11.Borehole diameter: 6° (fD,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r D ri I I
(ie.m�®er rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY ONLY: I� 24d.For Water Wells producins over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) © Method of best:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfectiontype: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018