GW1-2023-02901_Well Construction - GW1_20230418

•r..i..-,vVl\V 11\U 1..11V11 AICL.V.Lu/ (UT W-I) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher ..t=y. .,a t.;7 .','",;._.* _ Y -
Well Contractor Name FROM TO DESCRIPTION.--
,rti 2 46 ft G>it b. 5 s v/
ft ft
NC Well Contractor Certification Number
TO DIAMETERL THICKNESS MATERIAL
Frank A. Corriher& Sons Well Drilling, Inc. FROM
Company Name ft I {t in
T/y 1 WI2.Well Construction Permit#: / FROM TO DIAMETER TfiICIIHESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft 42 1/it 6 1/8 in- SDR-21 PVC
3.Well Use(check well use): ja L(ft. /o'-C. it 6 S7 C �t� 9 S.'/iv
, '
Water Supply Well: nail....-..j_ K�
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑ crpal/Public ft it.i in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 rt iti Fe;R.O A&., _ , 1*
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT<
Non-Water Supply Well: 0 it 22 ft Bentonite Hole Plug
DMonitoring ❑Recovery ft. ft -
Injection Well:
ft. ft
❑Aquifer Rerharge ❑GroundwaterRemediation
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD =
SL/ ❑Aquifer Test ❑Stormwater Drainage ft ft. ‘,
❑Experimental Technology .0 Subsidence Control ft. ft.
' ❑Geothermal(Closed Loop) . ❑Tracer a;W w o,\"ve7e4.:,. r ;;'•
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPITON jailor, ess, rare type,grain size,etc.)
Z. `� / ft. ft. ��i� D
d 4.Date Well(s)Completed:3-14-23 Well ID# ,,cp ft / wit /�',�,1,i� 1j
Q. 5a.Well Location: j'� / ,ft ;Is,,-c4- ' jG�� '
1K /mI47r)y Fryf. /€ft 3 ft 6,t�>>A- lc-
Facility/Owner Name Facility ID#(if applic ))gf�3 ft ft c;. u: :1'
ft\
' 5 s/K 7/i'yl_ l0cG `l) 6rnve2 ft APR 1 g 9090
1\t Physicals,City,and Zip may+ / ft .!
�'.,,• 3,D .
County Parcel Identification No.(PIN) -%
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) -
•
35t 3 `�. �� N 80 0 / / 22.Ce • atio
6.Is(are)the well(s): GJP"ermanent or ❑Temporary --) P '4-74:4, 2-/C -,2
Si ture of Cei ed 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 an existing well: ❑Yes or o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#2I 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 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 pages if necessary. •
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t9.5 (ft)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (�.
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 24b.For Injection Wells:On-) Copy to DWR,Underground Injection Control(IUC)
Air Drill .
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cabe
cable,direct posh,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copyto D
13a.Yield(gpm) Method of test:
6 Air Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1 �'R,CCPCUA
13b.Disinfection type: Sterilene Amount: ."a. ' S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018