GW1-2023-02903_Well Construction - GW1_20230418

..�,-.,..1 vs..11.,l l.IL/%.-.1 iv.L. nV.A.A. [cu (lx vv-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A �p ft �1 D it 2) a'
ft ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc.
FROM TO
DIAMETER THICKNESS- MATERIAL
Company Name ft ft m
2.Well Construction Permit#: (7 i FROM TO D °e
�� IAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft Y 7S ■t 6 1/8 _ in. SDR-21 PVC
3.Well Use(check well use): y
ft /3 J j��, /'/
Water Supply Well: V , / `
FROM TO a DIAMETER SLOT SIZE_ THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. it. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) we-ma „.>.3r _
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
DAquifer Storage and Recovery ❑Salinity Barrier P C _ . ..
FROM TO MATERIAL >.._., � }-EMPLACEMENT METHOD
CO ❑Aquifer Test IDStormwater Drainage, ft ft
[7Experimental Technology 0 Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer a sA C ;,�e ev...• a T.. .n _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarlt3) ROM ft ft DESC N lor, tnes�so-,vrock type,grain size,etc.) _
4.Date Wells)Completed:3--��,23 Well ID# � - 57) ft lam,-:2,ice`t)J ✓f/_ ,, P,
AJ 5a.Well Location: 9 y/ o C .)e L'e i eee-S ft j 4 s ft A 1 Li (CA c'L t="`-e____
acrin Lori Teri- ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
(/
0 � / t-� / 3 , /l/l /00f c/�1/,1gGiie f28a2-3 ft ft aPR P 7n2,�
Physical Address,CCii�ty,and Zip op/�) ft ft.
•,`1'' '" \.
County Parcel Identification No.(PIN)
> fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
cNi (if well field,one 1at/long is sufficient) 22.Ce • catio
35033 / " N 89 3l/� /? W
.., 0/12--&-e.Z C.?"Qg-09-1
6.IS(are)the well(s): rmanent or ❑Temporary Signature of Certified 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 o 15A NCAC 02C.0100 or 15A 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:
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 necessary.
drilled:
/'� 24.SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (Q (ft.)
For multiple wells list all depths if different(example-3(200'and V 2Q100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O( 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (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
Yield m O Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a
(gP ) Method of Air
test.
13b.Disinfection type: Sterilene Amount: .. Ci -S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018