_Well Construction - GW1_20230320 (28)

_•.s...a.a.vt I IJ l l%ll a..A A"114 A%JPI% %JAM I is W-11 For Intemal Use Only:
1.Well ContractorrInformation:
Ricky Corriher -
Well Contractor Name FROM TO DESCRIPTION
2464-A - Oft
ft ft
NC Well Contractor Certification Number
Frank A. Corriher 8t Sons Well Drilling, Inc. _
FROM TO11 DIAMETER THICKNESS MATERIAL
Company Name ft _J it in
2.Well Construction Permit#: FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Coun(y,State,Variance,etc.) +1 ft Lt ft 6 1/g 1D SDR-21 'PVC
3.Well Use(check well use): 7,0 it Lt 7 ft
D'
Water Supply Well: FROM -- TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
❑Agricultural,_ ❑ crpal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it- in
❑lndustrialtCommercial ❑Residential Water Supply(shared)
❑hri ation ❑W611S>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT '
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft /
Injection Well:
ft. it.
❑Aquifer Recharge ❑Groundwater Remediation
DA 4ifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tt ft
❑Experimental Technology, ❑Subsidence Control, ft ft
❑Geothermal(Closed Loop). ❑Tracer _
❑Geothermal(Heating(Cooling Return) ❑Other(e lain under#21 Remarks) FROr*I TO DES ON br, ess soil/roeic etc.)
D ft ft
4.Date Well(s)Completed:J V A J Well ID# ' 2 It. —'
5a.Well Location:7 1 /�zft r�,�
ft
Facility/owner FacilityID#(ifapplicablpf��� ft ft -
3g d VC 3
y' Address City,and zip i o
Phs , , Jo /04 ft ft
'
Canty Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one htt/lo ' '(' d, ng is sufficient)
i' t rma ! Y
ft 22.CeVation:35p<� 80 � W
&h(are)thewell(s): enent or ❑Temporary Signalise J
Well Contractor Date
� By signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to anris eting well: ❑Yes or tl o 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
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 conshvction,info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
!� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths if different(example-3 200'aand 1@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ( ) 24a• For All Wells: Original form to Division of Water Resources (DWR),
if water level it above casing,use"+" Infori a on Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in-) 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC)
Air Drill
(Le.auger,rotary,cable,direct push,etc.) Proles,1636 MSC,Raleigh,NC 27699-1636
.Well constriction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i county environmental health department of the county where installed
J
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells vroducins over 100,000 GPD-Co to D
�7 AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611 PY 'CCPCUA
13a.Yield(gpm)_ / Method of test
13b.Disinfection type: Sterllene Amount / '�O_a1S
� I
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised ti 6 2018
1 j i