GW1-2023-01914_Well Construction - GW1_20230222

,',..MAL VVlnLaaA\lJV1■Vl\lv.IliViW itT,,-1) rormmierl'lal Use Only P, I
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' 1.Well Contractor Information: - I,
Ricky Corriher :.
Well Contractor Name FROM' TO DESCRIPTION
2464-A: /t 1� a ed- : `, - .
NC Well Contractor Certification Number, ,--et. 32 c a/ I
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL-
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ft. i
ft.II I: in.Company Name -
2.Well Construction Permit#: e G / Q FROM ,TO yDIAMEfER TIOCf SS MATERIAL -
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 it b Z) it 611/8 'n- SDR-21 PVC \ •
3.Well Use(check well core): ' 6j.'0 ft i 2_ f. 6 rr 1 c cr I J
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICENESS MATERIAL
❑Aiticultural ❑ icipal/Public ft. • It. 1.
in.
- °Geothermal(Heating/Cooling Supply) esidential Water Supply(single). fy ft in. •
Olndustrial/Commercial ❑Residential Water Supply(shared) a• —
• Olaigation . ❑Wells>1001000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 22 ft Bentonite Hole Plug , _
°Monitoring . ❑Recovery' • ft it. I; ' ,
Injection Well: •
ft ft, '' -
°Aquifer Recharge - °Groundwater Remediation
°Aquifer Storage and Recovery • ❑Salinity Barrier - • FROM 1 To ..ml. inrtaaninerrMEiHon'
°Aquifer Test , , ❑Stormwater Drainage' ft ft.
OExpaimenfal Technology ❑Subsidence Control ft ft
❑Geothemral(Closed Loop) ❑Tracer --;!~. i.. ..:;� ,-.0-, —
❑Geothermal(Iieatiag/Cooling Return) ❑Other(explain ruder#21 Remarks) FROM TO DE ate- it(-cocolor,lea tosktype, size,ate.)
ft._ ''�e ft (; J1/�QJ/7J
4.Date Well(s)Completed: (—/) .. Well ID# 40 ft 6 L.fr- Il ' S �L
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5a Well lion Op LJt ye�- it ,1�11,1e s1 ZJ�k-4
• Facility/Owner Nameft ft
�. Facility (ifapplicableG/)fvXy it {; is,.•.,--,e'S.. �1
• 35i, t /P4Or R CRf /-t -T R a . -. - . ft c. ., & ..� , L� . .. .
Physical Address,City,and ft. ft FEB ? ? n,q
C iffP is y :d
County Parcel Identification No.(PIN) ,,nrvi'rl'1eb7 Pic.-:.&-s'tr.g 1-!r,ti
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong 35� ;�sufficient) 80 ,-- i 22.c �tio,
�. N ° l — W •-S % ,!� .K, ,it -
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6.Is(are)the well(s): it'Permanent or OTemporary Signature of• ed Well Contralctor Date
By signing this form,I hereby�fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: °Yes -or i I o _ ISA NCAC 02C.0100 or ISA NCAC 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:
You may use the hack of this,page to provide additional well construction info
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8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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construction,only 1 GW I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if ecrerary_
drilled:
- ' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: - q0 - ( )
For multiple wells list all depths ifdifllrent(example-3@200 and 2@I00') Submit this GW-1 within 301 days of well completion per the following:
10.Static water level below bop of casing: -
(R) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifxnrer level is above casing,use~+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: �o ' to
11.Borehole diameter 6 (in.) Copy DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,I,NC 27699-1636
12.Well construction method: Z4c For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,totazy,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:• If t
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA-
13a.Yield(gpm) Method of test:Air Pemut Program,1611 MSC,Raleigh,NC 27699-1611-
13b.Di infectiontype: Stenlene Amount 1/ -c p� l - '
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Form oW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018