GW1--03656_Well Construction - GW1_20230526

1.Well Contractor Information: '
Ricky Corriher
Weil Contactor Name FROM TO c r DESCRIPTION
2464-Ad ft �d ft D RIi:/ j`."� ro
•
ft
NC Well Contractor Certification Numberft I
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DInMETER THICIa rss „ai-nun
Company Name <,.�a ~ sa: t
-
2.Well Construction Permit#: FRoir1 TO Y DIAME ER T THICKNESS MATERIAL' I
List all applicable wit construction permits(i.e.UIC,County,State,Variance,etc.) . +1 ft 3� ft 6 1/8 in' SDR-21 PVC
32 - Li ft
, 1�� l
3.Well Use(check well use):
Water Supply Well:
• FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural • DM) pal/Public ft. ft in.
❑Geothermal(Heeting/Cooling Supply) It idential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -_--.
Olrrigation ❑Wells>100,000 GPD FROM TO MATERIAL, . EMPLACEI►IF.NTMETHOD&AMOUNT
Non-Water Supply Well: - 0 22 Bentonite Hole Plug
OMonitoring ❑Recovery ft. ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery OSalinity Barrier FROM, TO MATERIAL, - EMPLACEMENT METHOD
❑Agui�'Test ❑Stormwater Drainage ft.
❑Experimental Technology ❑Subsidence Control _ ft ft
OGeothermal(Closed Loop) OTracer ,; a P.a.>.z ; :_,:: :;,vT -,—,
❑Geothermal(Heafing/Cooling Returrn)��(( bother(explain under#21 Remarks) FROM U � J DEst olv( soar true t size etc.)
4.Date Well(s)Completed:.` 2 ',23 Well ID# ,'W ft ft.
5a.Well Location: 3 / ft e n "' A ,�
F<,0 'lL 1. (a rLo ti ft. ft. -'t< :.t Y• k c--E` 4r
Facility/Owner Name 'p Facility ID#(if appytyab)lr�d H- it
5?� I Ai M/. 4 i 4)��/ RetCe67M/ ``r� ft n. MAY 2023
C��4 RdRas ft. lnf�+':.. c itr� Una
:a: <a;wca:c,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees:
(if well field,one If/long' ctent)
/
z2.c . ,,pao,.350 f 1"/ N 800- 3C /O
of
Oze,i;,..-4
6.Is(are)the wells): ermanent or ❑Temporary Signature of tr.,' .ed Well Contractor I Date
7.Is this a repair to an existing well: ❑Yes or By signing this form,I hereby cerafy that the we11(s)was(were)constructed in accordance with
o 1SA NCAC 02C.0100 or 154 NC4C 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if nec ccaty,.
drilled:
n O 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1-)( ( )
For nrtdhple wells list all depths if 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: a WR
( ) 24a. For All Wells: Original form to Division of Water Resources
Ifnuier level is above casing use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 � )'
11.Borehole diameter: 6" Cm) b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC
11 Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636 )
(i a auger,rotary,cable,dhect 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
132 Yield(gpm) " 2 Method of test:Air' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount~ Cam„s
.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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