GW1--04174_Well Construction - GW1_20230706

-. -�v�.aWVViW l ►►-ll ror internal Use Only 1
' L Wen Contractor Information: •
Ricky Corriher •
wenccn2 Rune >ro_ D irsammon —--—- -___
' 2464-A .0 ! a. '
NC Well Contactor C Number
Frank A. Corriher&Sons Well Drilling, Inc. JAM TO D,,:;V.I. ,MI ---
Company Name
L Well Ponstraction Permit it:
Listalt appSeable well eombvuion permits(r e. Cou ty,stares etc.) +1 ft' /3( R 6 1/8 in' SDR-21
23111111111111
3.Well Use(check well ose): ., leanniral .c75-7gin. I MUM
r DM lic nor TO !.,'/:;ryw:.:65.7 r.1l4i..iii,,,r:;;c:.. -MAYgoiAL=
tmicipal/pub ft. ft. in.
aGeothermal(F +nP/CoolinSFP1Y) iResideabal Water Supply(single) R ft.•
_-_01 1-,:. Cammeayial °Residential Water Supply(shared) — - ` -
DWells>100,000GPD -= )'rT.,,avr:\awn.:Ian,T...;,c.,,r,,.a-t,,;,:!77:,.;;ml:ri
Non-Water Simply well: 0 22 ft- Bentonite Hole Plug
Monitoring t7Recovery fc ft.Injection ell: '
—
•
DAgniSaw Recharge .DGroundwater Remediation _ _ _ _- -----' — '— -- ,
DAqui�Stooge and Recovery OSalmrty Bather -- stnioin- 1,•,r ..-; .r r.:—: a;
Iji
DAquife r Test DStormwater Drainage ft- ft.
lTechnolvgy DS�Sidr�ceColnrrol' ft ft ,
DGeotb�l(Closed Loop) DTracer :•r T;_=-- _—_.,>_.•— ___— —
DGeothe�al(Eeatio�CoolmgRetian) DOther(e nlain-uer •
nd #21Remadss) © 'T' r •-l••'E L- , _. 1.•-i37♦
rari
4.Date Welts)Completed: � `J 0 Well ID# RineNtai 5 s' : vG!`
ft. ft
Sact a
ty/OwiName Facility (S•� b) ft ft
.7O� g t✓di-l d c1eve704cT ft' - all
PhygealAddiea,6ty,and Zip , ft. ft i
•
�
y Panel Id on No.(PIN) C a l:l�' j
' Sb.I'f'f ufa and longitude in degrees/minutes/seconds or decimal degrees:
(tfweU Sett,®e hmrlong is sufficient) _ t/
35pr'y /T x'80p �}2/�'�.3 w 22. `ton: / , _ _
• / � ��
6 Is(are)the we1(sr � t or DTemporary Signature of WeII ITaae
7.Is this a to an B"signingIhereby red that the xw11(s)was(were)constricted in accordance with
repairexisting well Dyes or 154 NC4C 02C.0100 or ISA NCAC 02CA200 Well Ca:sant4an Standards and that a
!Relit is a tep is..fill out balern well mnstructiw,information and a pleb,the native of the ofthis maid Ms be H p,vvide o,the ell owner.
repair' under 421 remarks section oron the back ofthisform-
23.Site diagram or additional well details:
&For GeoprobelDPT or Closed-Loop Geothermal Wells having the sane You may use the back of this page to provide additional wen
construction only 1 GW-1 is needed. dFndicate TOTAL NUMBER of wells (add'See Over'.in Remarks Box).You may also attach a p ges if info
dolled: {� 24.SUBMTITAL INSTRUCTIONS
9.r Total well' below land surface: f G- ( ) c
;mkt*w Est alldepmTss l�B+ (e le 3Q200'a;.d 2�to09
' ft Submit this GW-1 within 30 days of well co per the following: .
FH.Static water level bebw top of rasing: a O ( ) 24a. For All Wells: Original foam to Division of Water Reso
lfxaterlent is atoms crab use"+" Information 1'to ng Unit,1617 MSC,Raleigh,NC 27699-1617 urces (DWR),
24b.For Injection Wells:Copy to DWR,Underground InjectionInj Control(ItiC).
IL Borehole diameter:67 (n.)
12.Well construction method:Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
Cu. rotary,cable,cared push,etc.) Zoe.For Water Supplyand Open-Loop Geothermal
9 env>r ral health department of the Return Wells:Copy to the
FOR WATER SUPPLY WELLS ONLY: where installedA 24d.For Water Wells producing over 100,000 GPD:Copy
13a.Y (gpm1 ` ® Method of test Air P Pingram,16I1 MSC,Raleigh,NC 27699-1611 to DWR,CCPCUA
I3b.Di typ Sterilene Ameunt: a Cr,D,s . -
.,
r�,n,GW-1 Noah Carolina. .
Depaitmenr of Envimamenrai Quality-Division of Water.gewlaces ' Revised 6-6-2018
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