GW1-2023-02963_Well Construction - GW1_20230425

....�...,.,vi11..11lA.Ul.11V11 nn•1.-V1Cil (krW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
rw F yiJ)45.L S 2- 3s..'1^5r.>'� r.: 't L'°n'±+q'-._4bt>: ran... .p :c-.c
Well Contractor Name FROM TO DESCRIPTION
2464-A ��t �pj��
ft. ft
NC Well Contractor Certification Number e g:< ,y i,_ r
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICICNESS MATERIAL
n t ft ft in.
\V1 Company Name Ig 3y Gq
2.Well Construction Permit#: "J/y�(J ii FROM TO DIAMETER THICKNESS MATERIAL'
Q' List all applicable well construction permits(.e.UIC,County,State,Variance,etc.) +1 ft- ,4y ft 6 1/8 in. SDR-21 PVC
% 3.Well Use(check well use): y y ft y�, ft �Ytn ^/k -
_ v � 1%�
Water Supply Well: r t, ._ . w ..dam
FROM TO DIAMETER SLOT SIZE:: ,THICKNESS MATERIAL 4}
❑Agricultural ❑ unicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
N. ❑Industria]/Commerdial ❑Residential Water Supply(shared) ituswe,i r _13 .-`M
JN, ❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIALH EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation it ft _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology 0 Subsidence Control ft ft.
OGeothermal(Closed Loop) OTracer UM - l7 _.r _,
OGeothermal FROM TO DES ON(color,hardness,so' rook type,grain sirs,etc.)
: .(Heating/Cooling Return)) ❑Other(explain under#21 Remarks) © ft [�© ft / � 1 h t}��r
�' 4.Date Well(s)Completed:31`0 Well ID# ,a ft a ft 5.eiFp j 1 J/�
( Say W4 ell/L�ocation: Lta ft. JUsft /- A^ t-2-
ft. ft
tomny flumes'
Facility/OwnerN7< /'
Facility ID#(if applicable) - ��� ft tt M b 1�)l3
1~
�� 5 v 1 �/ ft ft
V Inksfft:.-,:ian i�r.. o
up:,
f Physical Address,�p City,/and Zip (� ft ft. Cs Q1 eOG
\1 _Iredl,//
Lam. 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 ' don.
3503 7/3�`i� N 80O y `— � �� W 1tgA�Ldr :?6.Is(are)the well(s): P�Permanent or ❑Temporary Signature of Cert• ed 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: Oyes or Ite 15A NCAC 02C.0100 or7SA 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 ofthis 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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
3 n� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V ft
For multiple wells list all depths ifdifferent(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: 60 ft 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" On) I 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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
(i e,auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co to D
--7Method of test:7Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 pY CCPCUA
13a.Yield(gpm)
13b.Disinfection type: Sterilene Amount: 3 Ya e�S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018