GW1--03736_Well Construction - GW1_20230602

•11•u"vl4a 1 MUL I It I V KLUORD (GW 1) For Internal Use Only:
1.Well contractor Information:
Ricky Corriher
Well Contractor Nam FROM TO DESCgg7.—
2464-A 6� S' ft y 4
NC Well Contractor Certification Nmmber ft
Frank A. Corriher& Sons Well Drilling, Inc. FROM r0 TIC
Company Name ft. ft MAT1 L
IM
/�
2.Well�oDStraction Permit#: J V 3 FROM To DiA 4
Iirt aII aPpGeabk retell mnstrucdonPermrts(I e.U1C,Cowuv, MATERIAL
score Parlance etc.) +1 it 6 1/8 UL SDR-21 PVC
3.Well Use(check well use): ft ft in
Water Supply Well:
❑Agucultiu ❑al ipaV FROM TO Public DIAMSrER SLOT SIZE THICKC MATERIAL
OGeoth-mal(Heating/Cooh g Supply) i- atial Water Supply(single)
❑Industrial/Commercial ft in
❑Residential Water Supply(shared)
on
No*- to OWells>100,000 GPD FROM TO Mggg L
Non-Water Supply Well: ���'i'MrrTnon&AMotmrt
p ft 22 Bentonite Hole Plug
OMonitn W ❑Recovery ft
Injection Well: �
OAgt fer Recharge ❑Groundwater Remediation ft ft
OAgmfea Storage and Recovery OSalinity Barrier FROM TO MATERIALMEN
OAqutfer Test ❑Stormwater Ihainage ffi ft EMrLAc�vr Mz Taon
OExPelimental Technology OSubsidence Control ft.
ft
OGeotheamal(closed Loop) ❑Tracer
OGeotheimal g/Cooling Retum). ❑Other(expiain'undcr#21 Remarks) 0 TO D o rnror, ,
M fz
4.Date Well(s)Completed 5-3-0-0— Well ID# �/% I Cdi ft.
S
5a.Well Location: 7 O IL 02!S f t�C!i
1 ar;C"'� IZ am - ft. fL oc)
Facility/OwaerName v
� Facility rD#(if applicable) ft fL
Physkal A&h ecs,City,and Zip yI re { ft.rat ,U O 13 - -
County Parcel Identification No.(PIN)
510.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laving is sufficient)
35-o 2 80() %® / /� zz.c ratio
N W
6.Is(are)the weII(s): ermanent or OTemporary Signanre of ed well contrmtor
- Dane
7.Lc this a repair to an 'signing thisfotm,f herebv certify that the w13ll(s)was(were)constructed in accordance wth
p eAsting w�' ❑Yes or Z14111 15A NCAC 01C.0100 or 15A NCAC 01C.0100 iPe11 ConstNctio„
Ifthis is a repair.ftU out!mown i+r11 construction information ar d explain the native of the of this record has been Provided to the tti ell owner Stmmdards and that a copy
repair tmder#21 retnarha section or on the back oft;w form_
23.Site diagram or additional well details:
8. s t Ge u,Only
or s n Closed-Loop i Geothermal Webs having the same You may use the back of this page to provide additional well constmction info
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells (add Over.in Remarks Box).You may also attach addition pages if necessary.
drilled
�^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells fist all d i ( p ( (f t) Submit this GW-1
eptlts fdifferent exam le-3 oo-and 1(a)100o within 30 days of well completion per the following-
10.Static water level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources
(I)WR)
ymiter level is above casrnp„use~+ lnfom�ation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6° (m) 24b.For Iniection Wells:Copy to DWR,Und
/� Program, 1636 MSC,Raleigh,PY to D F,U mound Injection Control(IUC).
12.Well construction method:Air Drill
(Le.a'19--mtaxY,cable,direct push,ear.) 24c.For Water Supply and Open-Loop Geothermal Return Wp,JRpy the
county cuvrronmenrai health department of the county where installed
FOR WATER SUPPLY WELLS ONLY.
24d.For Water Wells ptoducinQ over 100 000 GPD Co to D
I3a. lgPm) Method of testi Air Permtt Program 1611 MSC,Raletgh,NC 27699-1611 PY wR,CCPCUA
13b.Disinfection type: Sterilene Amount: C� S
Form GW-1, North Carolina Department of Environmental Quallty_Di,..of Water Resources
• Revised 6-6-2018