GW1-2023-02318_Well Construction - GW1_20230331

1.Well Contractor Information: I
Ricky Corriher ` , :_T,
WcllContxactorName FROM TO DESCRIP1IOx _
2464-A ll - �7 2. 1
ft ft
NC Well Contactor Certification Number
/ FROM `'TO DIAMETERirstoons .�. A :.
Frank A. Corriher& Sons Well Drilling, Inc. I
ft ft. in.
Company Name ,3 _
`FROM TO, THICKNESS MATERIAL
2.well Construction Permit#: �9 1 S/5
DIAw r R
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) . +1
/ `j ft 61/8/ '° SDR-21 PVC
3.well Use(check well use): 1` // t'C $ 1� ' Q1 1/
Wafer Supply Weib FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgri uhu al D� 1pal/Public tt ft M.
(H
❑Geothermal " e/Cooling Supply) Water Supply(single) ft ft. in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) -_ -
Dltxigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • 0 f' 22 ft Bentonite Hole Plug
' DIVtonitormg ❑Recovery ft ft
Injection well: •
it ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM` :TO�.-~- •- Mp1 1,V - .EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed loop) ❑Tracer :_ . ! .>.s -
°Geodlermal(H�*inp/Cooling Return) ❑Other(explain under#21 Remarks)
FROM ft.
O.0 ft D R R oN amyrod:tma size,etc.)
Date Well(s)completed %' welt»# Za ft /0 t I P-�
Facility/Owner Name Facility IIDDU(if applicable)
/ ee71X _ _. -<-•
ia
hysical Address,City,and rip
PJ2d 4 /36'0'39 ft rn ?n73� _
Cry Parcel Identification No.(PIN) �a ;Di r ^^�l�❑i
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Iat1ong is sufficient) / // 22.Certifi Lion:
3503/ 8 N 80G -33 -' I W44( Z
,:Z 3-9—23.
6.Is(are)the wags): Permanent or DTemporary Signature of Cenifled WelrCoanactor
Date
By signing this form,Thereby certify'that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: [Wes or Celle 15,4 NCAC O2C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a cops,
Ifthis is a repair,fill out known well construction inf rnwtion and esplaln the nature of the ofthis record has been provided to the well owlet..
repair under#21 remarla section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You'may use the back of this page to provide additional well construction info
ccolt nstruction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
/J 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-7 5
For multiple wells list all dept s jfd (example-g()a 200'and 2@1003 (ft)
Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 7 0 ( ) m 24a. For All Wells: Original for to Division of Water Resources (DWR),
Ifwaaer fewel is above caring use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617,
24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter:6" (in)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie auk rotary,cable,direct push,etc.) county environmental health,department of the count
y where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing
n I/O, P cmR over 100,000 GPD:Copy to DWR,CCPCUA
13a_Yield(gpm) Ot / Method of test Apt r Petits Program,1611 MSC,Raleigh,NC 27699-1611
' 73b.Disinfection type: Sterilene Amount 6 C e' -
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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