GW1--03328_Well Construction - GW1_20230512

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1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A XL
ft. ft-
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. -
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ����� ^-
ft ft
2.Well Construction Permit#: j\vl/ FROM To D THICTOWEss
MATERIAL
.LatallaPP Ucable well construca on pam lb(ce.WC,County,State,Variance,etc ftft6 1/8 in SDR-21 PVC
3.Well Use(check well use): ft [t
Water Supply Well: i d
FROM TO DIAMET SLOT SrLE THICKNESS MATERIAL
❑Agriculttual ❑ cipal/Public ft. ft is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared)
DIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL, EMPLACENIENTMETHOD&AMOUNT
Non-Water Supply Well: O fL 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft -ft-
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft it
❑Aquifer Storage and Recovery ❑Salinity"Barrier FROM TO MATERIAL EMPLACFMENrMETTIOD
❑Aquifer Test ❑Stormwater Drainage M ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooliug Return) ❑Other(explain under#21 Remarks) FROM To D ON color,tvudnms w,yrve} sum,�
rt e.
4.Date Well(s)CompletedA/_9 6 Well.ID# - ft
"ttSS 5a.well lion: ft.
tJl eT ft. it
�i Far" /Owner Name ft r
O.O q � / � Facility ID#(if applicable) ft
/Je- ve �i�/Ir�ef i 5 It fL
PhQ`�Cuy AY
ft fL � �
ed _
Comity Farrel Identification No.(PIN) i'J Q"a t j u'1L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,me lattlong' sufficient
35® 1 1/ ! )N oOD -39 � 5-© � 22.Ce tion:
_ v v/ W _ y �
6..Is(are)the well(s): ermaneat or ❑Temporary Sigttatme of Well Contractor Date
By signing this form,I hereby certrfv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 1 SA NG1C 02C.0200 If fVell Construction Standards and drag a gyp„
this is a repairfrll, out known well construction information and explain the nature of the oftlus record has been provided to the well owner
repair u th
under#21 remarks section or on e 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 I GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
C� 24.SfJBMMAL INSTRUCTIONS
9.Total well depth below land surface: p`. (ft-)For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of rasing:- Q (ft) 24a For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above rasing use-,1. 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)
12.Well construction method:
Air Drill Prograta, 1636 MSC,Raleigh,NC 27699-1636
(i:e.auger•rotary,cable,direct push,etc") 24c.For Water Snaply and Open-Loop Geothermal Return Wells Copy to the
county envrronmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
L 24d.For Water Wells prnducin over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Peffirt Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018
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