GW1--03730_Well Construction - GW1_20230602

WELL CON
For Internal Use Only:
L Well Contractor Information:
Ricky Corriher
WCU U0U actor Name FROM TO=1D2464-A ft.
NC Well Contractor Certification Number ftfL
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO, DIAMh'IgR St it. T�
MATERIAL
CXNM
Company Name eLs a L� ft c in.
2.Well Conshuction Permit#: / . / �O —
FROM TO DL>MErER MATERIAL
Litt all applicable hell construction perm (r e.UIC,Cowes. ate,Variance,etc.) i 1 fL `�y 6 1�8
Tglt g
3.Well Use(check well Use); SDR-21 PVC
fL
Water Supply Well: 9 (/
❑AgriCultural ❑McipaVPublic FROM fL To fL nIAMgIER sLozslZE THIC6Ss MATERLLL.
❑Geothermal(K-ting(Cooling Supply) ResidenUL
tial Water Supply(single)
❑IndustriaVCommercial ❑Resid fL in. J
ential Water Supply(shared)
❑ on ❑Wells>100,000 GPD FROM TO
No-Water Supply Well: MATERIAL � TI g nM uNr
❑Recovery METHOD&
❑Monitoring 22 ' Bentonite Hole Plug
tt Injection Well fL: .
❑Aquifer Recharge ❑Groundwater Remediation n ft.
C ❑Aquifeer Storage and Recovery ❑Salinity Barrier J FROM TO -
N ❑Aquifer Test - - ❑Stormwater Drainage ft fL `� A TKUHOD
❑Experimental Technology ❑Subsidence Connvl- fL rL
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Hey"(Cooling Retum) ❑Other(explain'under#21 Remarks) FROM TO Duct rmm rtp mnbr . Weock ®a eEll ft. CIA—
/✓4.Date Wen(s)Completed: '�3 Well ID#
L 52.Well Loca''liar (�� fL L 1
/ ) n ! !
� �..QQ� �'�Ot i" /1 +17U2��i�/iS'o/7 rL n
FacildylOwnerName Facility M#(ifapplicable) ft fL221
�t1Y t�
�rroi R It J I!
Physmcal GYty,and Ztp �_ � fL ft.
O C✓c
Parcel Identification No.(PII4
5b.Latitude and longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one lavlong is sufficient)
35 o.'?� 80 / 1 t 22.Certifi tion:
N J �® W J
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ad Well Contractr �_c
Date
1 Is this a repair to an existing well: ❑Yes or By signing thisform,1 hereby certifv that the xea(s)moms(were)consttuded m accordance with
If".is. repayout brown xw11a ons8uetion information and explain the n a o 15"NCRC 02C.0100 or ISA NCAC 02C.Oz00 WeU bonytrvcnon Staudt ds and drat a copy,
repair wider#z1 rvnarla•sector or on the back o ature ofthe ofdw record has been provided to the well owns
fthis form.
23.Site diagram or additional well details:
8.For GeoprobeMP'T or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info•
drilled:- on 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: [' / L�
9.Total well depth below land surface: T J 24.SUBMTiTAI,INSTRUCTIONS
For multiple wells.list all depths ifdiffermr(example-3@200'and z�100� UL) Submit this GW-1 within 30 days of well completion
^� mp per the following:
10.Static water level below top of casing: !� 24a. For All Wells: Original form to Division of Water Resources
lfwater level is above casing use"+' UL) J formation Processin utter (D�),
g Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6° Cm.) 246.For Injection Wells
Pro COPY to D WR,Underground Injection Control(IUC).
12.Well construction method.Air Drill �,1636 MSC,Raleigh,NC 27699-1636
(ie.yoke,rotary,cable.dim push,ern.) 24c For Water Supply and opeitMOR Geothermal Return Wells Copy to the
FOR WATER SUPPLY WELLS ONLY: coOnty envuonmental health department of the county where nrstalled
24d For Water Wells producing over 100 000 GPD Co to D
13a.Yield(gPm) ++ Method of test:Air PCIM t Program.1 111 MSC,Raleigh,er 00 000 161 1 Copy
WP CcpCU�'
I3b.Dismf"ectiontype; �7terilene
Amount: cn S
Form GW-1 North Carolina
Department of Environmental Quality-Division of Water Resaaces .
Revised 6.6-2018