GW1-2023-02904_Well Construction - GW1_20230418

........a.vi11.3ilA.U1,...11V1\ L'L VICLJ (LTW-1 For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRH'TION
2464-A �- k ft
ft- l a
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name / - y ci � y '~.Y
—7 1?6
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,St e,Variance,etc.) . +1 ft Z 'ft 6 1/8 in. SD R-21 PVC
3.Well Use(check well use): O •,Oft to S 1t /),bi j c' hi
Water Supply Well: r 2
FROM TO DIAMETER SLOT SIZE__- THICKNESS MATERIAL
DAgricultural ❑ unicipalfPublic ft. It . in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared),r6.„3„:-.7;
❑hrigation ❑Wells>L100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT„
Non-Water Supply.Well: 0 ft 22 ft Bentonite . Hole Plug
\ ❑Monitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge 0 Groundwater Remediation ft it
A11�I1. -. ca '9Fe a ._-
❑ infer Sto a and Recove ❑ Barrier p' -"--"
Recovery
Salinity FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology 0 Subsidence Control ft. ft.
`�\ ❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM T��o��r, D CRICTION(�b tuudness soWroelc
( O ft :IC) ft. 'c-C.. type.
(;+�s3u,ete.1
p !�� to -
\ 4.Date Well(s)Completed -'t r r� Well ID/# 3 ft �i j ft J�� / /C
5a.Well Locatijo : C 42,*r Poi.4 4" b i,u lItefS 3 O ft ,�.of /-S t tc•e 4- W 1Vbhe✓ �J'�"h
Larry 1 0 Tr SO/1 ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
ft ftCS es
AP{��, �yy
Physical Address,City,and Zip - 1 `7.' it ft I' I. 0 21�2)
/� So ll / / OV
s....) County Parcel Identification No.(PIN) '_,'' 2
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p
3503a. i l /! N 8Oa---a�t 5'� ,r 22.Ce • ation
�� w 0/ ,,, 4 3- 3.-ate
6.Is(are)the well(s): QPermanent or ❑Temporary Signature of Certified Well Contractor i Date
/
By signing this form,l hereby cernfv 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 GeoprobefDPT 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 1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
05 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: p[ (ft)
For multiple wells list all depths ifd different(example-3@200'and
2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 3 V ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing use"+ ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6" (in.)
12.Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(ie.auger,rotary,cables,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) q Method of test: Raleigh,Air Permit Program,1611 MSC,Ralei l� oC
NC 27699-1611
�
13b.Disinfection type: Sterilene Amount: n caps
.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised ti 6 2018