GW1-2022-09588_Well Construction - GW1_20221021

WELL UU1V TKUUTIUA KLt uu"f uw-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
TO
weu comer Name
FROM DESCRD'IION
2464-A 11
ft ft. I.
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. °M TO DLOWTM TMCKNM I KkTNUAL
ft. tt in.
Cou"ay Name
2.Well Construction Permit# 7 / quo FR°M TO D1ANl M THICENESS MATERL41
Last au applicable well construction permits rLe.UIG County,State,variance,etc.) +1 0- VS-fL 6 1/6 1° SDR-21 PVC
3.Well Use(check well use): Z 3 ft 6
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ ipal/Public fL ft in.
OGeod-mal(Heating/Coolingsupply) Residential Water Supply(single) ft. ft. in.
❑h ds,_shia/Comm=ciai ❑Residential Water Supply(shared)
01[rization O Wells>100,000 GPD FROM TO MATERIAL FAIPI.ACEhlENNT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 22 ft Ben'tonite Hole Plug
OMonitoring ORecovery ft. ft
Injection Well:
i ft ft
OAquifer Recharge OGroundwater Remediation ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAC8MMIrrMETHOD
❑Aquifer Test OStorrawater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer . _ _
FROM TO D O eob so�yrocit d&
013eothemuS(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D fL 20 ft.
4.Date Well(s)Completed 0 �W u ID# .�ft-TM,
O(
5a.Well Location: 3 fL 4i - t.G
Pa 1�aI7
Facility/Owner Name Facility ID#(if licabie) fL iL
Physical Address,CSty,and Zip _ UPA
Roam 79q 0 7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minatestsecouds or decimal degrees:
(if well field,one laz%ng is sufficient) 22.C ratio
356 (i ' �� N 80d � � 7 `� W -
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ed Well Contractor. Date
Bysigning thisform,I herebv tfy1 that rye-U(s)was(were)constructed in accordance wick
,�,
7.Is this a repair to an existing well: Oyes or � 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a cop„
If this is a repair,fill out bwwn well construction information and explain the nature of the of this record has been provided to the well owner.
repair wider#21 rentarla section or on the back of this form.
23.Site diagram or additional well details:
8-For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I 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 ` Submit this GW-1 within 30 days wig_
us fist all depths depth below land surface:
if dif jerent(example-3@200'and 2Qa 100� ( )
For mu4k we ys of well completion per the folio
10.Static water level below top of casing: 3or ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If inter level is above casin&use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6° (Ji-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method,Air Drill
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return wells:Copy to the
county envuonmental health departtaent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD•Co Permit Pro PY to D WR CCPCUA
13a.Yield(gpm) Method of test:Air P l ice,1611 MSC,Raleigh NC 27699-1 6 1 1
13b.Disinfection type. Sterilene Amount: _
Form GW-1 North Caroibma Department of Environmental Quality-Division of Water Resources Revised 6-6-2018