GW1-2023-02319_Well Construction - GW1_20230331

••aadAa v VA IL,11\l.J t.11V11 iLL,UXU, 1 lit Vv—i j For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _,�,_
_r3•�., ��o�,xa-. -_� ALL:: ' Yt' .... . ..,.,,---
Well Contractor Name FROM TO DESCRIPTION
2464-A 026eht 3 e) 9 ?/
ft. ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name 1
2.Well Construction Permit#: -30 FROM TO DIAMETER THICKNESS MATERIAL
T
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft )p2_ I` 6 1/8 in' SDR-21 PVC
3.Well Use(check well use): Q. /2-Cit / 5 / ' q n lc/
Water Supply Well: '� = x,y r t: .. _ !_ . _ ._ ... _
FROM TO DIAMETER SLOT SIZE `THICKNESS .MATERIAL
' °Agricultural ❑ ,,.•cipal/Public ft. it in.
❑Geothermal(Heating/Cooling Supply) . P.'esidential Water Supply(single) It it in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 . ft Bentonite Hole Plug
❑Monitoring _ ❑Recovery , ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
EISTAVIulfer Storage ,� ,7,--07f �
❑Aq ' and Recovery ❑Salinity Bather FROM TO 1 MATERIAL EMPLACEMENT METHOD
I ❑Aquifer Test ❑Stormwater Drainage ft ft
°Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑TracerFROM TO• istw6 , ae ,"7 - `
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ` /7It D oN/(c°b hard"ess s";yrarcl size,etc.)
!} < IJ Cat r j-' / P
4.Date Well(s)Completed:3—/ A Well ID# //C1 ft / g it , s/ r -: IC- �(�, /SaW/ell Lo tion: , / it 3t lc� 1 u V`tom �vt/�t'C.6 r�a'i t t
p a ifi e 1✓/ cnoil®�°i� ft ft �.. t y ,3
Facility/Owner Name
�+ -Par
Facility ID#(if applicable)p ft ft s'� 1
75 1/'fT t_' 11 a c7 /,4 cA6//) ft ft �`viAR 3 1 zLIZJ •
Physical Address,City,and Zip ft ft -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce ' cation:
35J ' � N'� 800 —��� fq ��
w _ /i , A4:4, 2
6.Is(are)the well(s): �Peimanent or ❑Temporary Signature of CettfSed Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or eke 1SA NCAC 02C.0100 or 1SA 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. -
i i 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
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add Over'in Remarks Box).You may also attach additional pages if nerrccary•
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 d- (ft)
For multiple wells list all depths if different(example-3(l200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
•
10.Static water level below top of casing: 171C? 24a. For All Wells: Original form to Division of Water Resources (DWR),
((water level is above casing use"+ (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: sn (In•) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(ie.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health'department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: 3 "10S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
i Revised 6-6-2018