HomeMy WebLinkAboutGW1--04987_Well Construction - GW1_20230807 •
—----.- ..e...-a► for Internal Use Only.
1.Well Contractor Information: ,
Ricky Corriher _
2464- !home •
iM= — Dom_---- ___:—
biC Well Co Certification Number ft
Frank A. Corriher& Sons Well Drilling, Inc. M `� - -�D �- -s _
CompanyName (�C; 1I /yJ "�`\�'�n� ft. AMETER MATERIAL--
e n Permit#: 2 0 1' 0 j d PROM '`TO — � ; RI lc --—— --
le well construction permits(i.e.(1IC,County, o7AD ` TES T.state,Variance,etc.) +1 ft. • 7 ft 6 1/8 m• SDR-21
3.Well use(check well use): ft MEM
' Water Supply Well: O _ -�/ ft I G'p /f
DAgriculimal FRM ro —.. — --
OM aVPublic nlurit srorslz$i Ci T=
DGeothemral(1j�•ing/Cooling Supply) - - Water ft tit in. • ��
IIIIIIII
• . OIndushial/ Supply(single) ft in. __
Commerzral DResideatial Water Supply(shared) .-
olmgation DWells>100,000 GPD FROM TO -
Supply Wen: aaHpoxr
DMonito hg DRecovery ft0 ft' Benton a Hole Plug
Injection Well: - ft
°Aquifer Recharge ❑Groundwater Remediaiion
DAtpit>$Storage and Recovery °Salinity Flamer l 1=> - '` ==' -7. n • - —_ '-----------------
°Aquifer Test > l ?o --- -- --
OStoamwaterDraiaage ft ft. rlHOD`
1 erimentalTechnology OSubcide nreControl'. ft. 11111.11.1111111
O (Chased gyp) OTmccrPl ft-
(Heating/Cooling Return) DVWLr(-xp.a.rt u de #2 Remarks) ' tit i h M I / ~- / ' �• --
4-Date Wells)Completed: ///77 23 Well ID# �/ ft. R ' f3/b �/l}jo •
sa Well ,
u
�j
T. FeCilWOwnerName . F ID# if )Var'J30
ft
' PhysM: Address,
6I / 0`115 oari r�k�eI - _ft.`� road :z::
Parcel Identification No.(PIt� -"
14). 5b.Latitude and
longitude dew-eta/minutes/seconds or decimal degrees: Inf :b:m 1`arnr a4ag Ur,
35 - one i . 80 22. ;:. .
N W �
6 Is(are)the w / r/ t'iractor 7y •
-
eS(s):rQPesmanent or OTemporary Signature of- Well Conuattor,
Date
7.Is this a Sy signing thisfean,!hereby certify that the well(s)war(were)constructed nt accordmue with
repair to an existing well: DYes or o ISA NCAC 02C.0100 or ISA NCeiC 02C.0200 Well Construrto„
!fais is a repair.fill out bums well oonsbw�ion&&formation and explain the nature of the off record has been provided to the sell tart drat a copy.
r under#21 reotatis section or an the back of this farm_ owner. Pw
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8 For Geoproh dDPT or Closed-Loop 23.Site diagram or additional well details:
construction,only 1 GW-1 is needed Indicate T�Wells
of ving wells e (add'See Ovet.m back You may uSe the of Bthit).Youo to provide additional well pag ifnec no.drilled: Remarks Box). may also attach � �
24_SUBMITTAL INSTRIICTIONS
9.Totalwen depth below land surface: 6Formttltg&le wells list all deP lfd+Baort(3mr&ple�3 00'and 2Q100� (ft.) Submit this GW-1 within 30 da of w
Ys ell completion per the foliowing_ .
30.Static watt level top of casing: ( ) 24a. For AIa Wells: Original foma to Division of Water Resources (DWR
'twofer10.St is is water
labove el below„ +- Information Processing-Unit,1617 MSC,Raleigh, ),
6" NC 27699-1617
11.Borehole diameter (m,) 24b.For Injection Wens:CoNp ,2to DWR,Underground Injection Control(TUC).
. 12.Well construction method:Air Drill ° ,1636 MSC,Raleigh, C,27699-1636
(t°• Y,cable,dyed push,etc.) 24a For Water Sanely and Ooen-Loon Re Copy to the
Geothermal`
FOR WATER SUPPLY WELLS C ONLY: healthcounty envrtonmental of the county when
�; J'
24d.For Water Wells rode ' over 100 000 GPD-Co
13a.Yield�) i Method of test Air Peanit Pmgtam,1611 MSC,Raleigh,NC 27699-1611-Cop to DWR,CCPCUA
13b.Disinfectiontype: Sterilene AmouIIt 9'ce/5
Form GW-1
North Carolina Department of Envitonmensar Witty-Division of Water Resources
Revised 6-6-2018
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