GW1--03439_Well Construction - GW1_20230516

. ..—... vvlwll\Vl..i1Vl\ .mjA.A,Jco (tyvv-I) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher d„,P , ;, , _ y , r
Well Contractor Name FROM TO DESCRIPTION
'` '=
2464=Q 56�t l Zc-ft 3 0 5 c
ft ft
NC Well d tractor Certification Number (
Frank A.Corriher& Sons Well Drilling, Inc. FROM 1 To [0L4METER THICKNsss MATERIAL
Company Name in.
9,2.Well.Construction Permit#: FROM TO DIAMETER THICKNESS Y,MA -- -�,
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) t 1 ft -7 3 ft 6 1/8 in. SDR-21 PVC
3.Well Use(check well use): 7 3 it 7 5ft .4-7
Water Supply Well: _ ? x,. /�i� 03 c�!1
xs
❑Agricultural ❑ •ci al/Public FROM TO I DIAMETER SLOT SIZE '` THICKNESS MATERIAL
P ft ft. in.
❑Geothermal(Heating/Cooling Supply) I•i'esidential Water Supply(single) rt. St in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,,,..
-
❑Irrigation • ❑Wells>100,000,GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 22 it Bentonite Hole Plug
OMonitoring ❑Recovery ft. ft.
Injection Well:
it ft.
OAquifer Recharge ❑Groundwater Remediation -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO l -
MATERRI AL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control ' ft ft
c ❑Geothermal(Closed Loop) ❑Tracert20lIlI
V OGeothermal(Heating/Cooling Return) ❑Other(explain"under#21 Remarks) FROM TO DESCRn']ION(eater,hardness,so;vrock type,grain sae,etc.)
4.Date Well(s)Completed:c7 L 0� o3 Well ID# go it 6 0 ft ,nab' /Jn
Sa Well)Location: G�' ft 7�-tE s,b C r / c,G J
eJ (TAh 66GC G� - S—it /e� i. L3' `'--rt/ ()�� K. _
Facility/Owner Name Facility ID#(if applicable) ft ft
l qq0 llrfP �S kci .sit/,si, .2S 7 y 7 ft ft
Physi ddress,City,5ficrip ft ft
County "' o N } -,.....•;
Parcel Identification No.(PIN) 1 .k wa w i �. .,j..
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MAY
A v
(if well field,one lat/long is sufficient) p •
g "�`` 1 2023
35 vrp t/) 800 -3 y f 3-y t/ 22.Ce ation
N / .
w �f In c;_-,-:� y� �r}�..,
6.Is(are)the well(s): Q(Permanent or ❑Temporary Signature of 'Red Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!fair is r pair,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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.'
drilled:
J f 24•SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �i ( )
For multiple wells list all depths if dii ferent(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: a O (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above caring,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
II.Borehole diameter: 6" (0,)
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
(i.e.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:
0
24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 3 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: G'CyQS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018