GW1-2023-02902_Well Construction - GW1_20230418

••a.ada.l..•Vl\v A AN IL,1-.I.JUL111 i ..&'ISL l it W-11 For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
iyr4' ,,,al%f e3.%.;:X to v#' '""...,.-r
=- ,...,..':'ram • � a. _ .r.:_
Well Contractor Name FROM TO DES ONE~
2464-A la ft 9& ft / q ..
ft ft �/
NC Well Contractor Certification Number
3 K'';0 @;t K'r3: iarY.'8 .asr'Rt6 1.3c 3.;:q-E..7ry^.^i f5 4;#
Frank A. Corriher& Sons Well, Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft ft is I
2.Well Construction Permit#: /19 9 ‘ FROM TO DIAMETER THICKNESS ~MATERIAL '
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft 11 ft 61/8 in' S DR-21 PVC
3.Well Use(check well use): frtyft r,, ft t S! i t ` e •p
Water Supply Well: x `z: s, _ _, _
FROM TO DIAMETER SLOT SIZE W�THICI NESS MAI-EgIAL -_
❑Agricultural ❑M cipal/Public ft. ft in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
‘0
((�� ❑Industrial/Commercial ❑Residential Water Supply(shared) itw- ,r,:�'_ r.r -Ty -;:-.-.,-....„.-._:..-_,i
__
v \ _...,.� -mot,:.: .. ..5r -..- . .. '-k. ::_~� .-',e-•
❑hrigation ❑Wells>100,000GPD FROM TO MATERIAL _ EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
• ❑Monitoring ❑Recovery ft. it
Injection Well:
ft ft
--- ❑Aquifer Recharge ❑Groundwater Remediation
r ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MAT aT
MATERIAL
EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft it
c 1 ❑Experimental Technology 0 Subsidence Control f. ft
❑Geothermal(Closed Loop) OTracer i si P:N .eP. _.
❑GeothermalFROM TO DESCRu'TiON(eobr,hardness sowr ck
(Heating/Cooling Return)L] f /❑�/Other(explain under#21 Remarks) N lr w 4-�type size,etc)
3 (/i t `Ot ft.
t t O ft �f'\{f / !�CiE.
4.Date Well(s)Completed: ell ID# �,Q ft �''�ft. 6� J
si 5a.Well Location: / S T .ft e L)_ 6 j�� & J
/)y/,o\m l C Oel/e( eC5Ofif 1 ft ft l�
Facility/Owner Name ��ta 1 r ft
C' tY Facility ID#(if applicable) ft
//5 krfrl/! LO70P/--d -X7'r) t 6.??Pr ft ft np
Physical Address,City,and Zip ft. it H!n
o rn/'ci// /2 e,90
LUZ3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certificatio
•
35p 3 /ie�/ N 80039 9e W a, * ��
,,„,..„,,V.
3 -(2/g
rm 3
6.1s(are)the well(s): i21 anent or ❑Temporary Sil rat o i5ed 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 lit( 114 NCAC 02C.0100 or ISA NC,4C 02C.0200 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 GeoprobelDPT,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: G-�
For multiple wells list all depths if different(example-3@200'and 2@100') (f t) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 95 ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" kit) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(ie,auger,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 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
13b.Disinfection type: Sterilene Amount: a' i. Cpps
Form GW-1 North Carolina Department of Environmental Quality '
-Division of Water Resources Revised 6-6-2018