GW1--04196_Well Construction - GW1_20230706

..a:.a..,a..vl\rl I xu L.I WIN KECORD (Gan-1) For Internal Use may:
1.Well Contractor Information:
Ricky Corriher -•
-
WellConhactorNa� a:. ;;_ — __
DESCRIPTION
2464-A .0 f° f ft o
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. •.. ,- "�` �lm r =- _
Company Name ft ft
_ ! w MATE[tlpL
�a3 ��G 1s a �.' } ,rf. ,t,,.
2.Well Construction Permit#: FROM TO ,r,�,, - � _-MhTE t.--=
!) .�arai♦ir rCw.�i��� MATERIAL
List all applicable well construction permits(ie.VIC.County,Cr.,te,Variance,etc.) +1 ft il 6 1/8 m•
3.well Use(check well use): SDR-21 P,VC
Water Supply Well: -
FROM TO 10r1,514.*:A 11 SLOTSIZB -"��
❑Agricultural 0 >„- ..al/Public (t ft r w..+,�. "=
❑Geothermal(Heating/Cooling Supply) 0'=-identiai Water Supply
❑lndusQia1fCommercial upP Y(single) fL ft _
in
—
❑Resid�ntial Water Supply(shared) 0.�-, ,_ .
❑hrigation ❑Wells>100,000 GPD To . ; �+ 1�w:C#s„ta:1+z 14#(O,E7i
Non-Water Supply Well: 0 f- 22 ft Bentonite Hole Plug
DMonitoiing ❑Recovery ft ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
0 Aquifer TStorageandRecovery ❑S3linityBarrier FROM EElyMATEttIAL !7Z-'wjra ,a silvra..:(q'a
❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control' ft ft.
❑Geoihe>mal(Closed Loop) OTracer
❑Geothennal(Heattng/CoolingRetum) pother(explain'under#21Remarks) �i l__C z n '
4.Date Well(s)Completed: 4 1 v '3 Well TD# .- IMUIVIEMIIIIErtnig=111111111111111
Sa.Well Location: RIM 0 ft 11lWnllnMaIIIIIIIIIIIII
Facility/ownerName Facility ID#(if applicable) b ft ft.
5 L- vo Or 1 v e Pu 1inn,n i.l c ft. ft. 111111.11111IMMIIIIIIII
ft
Ph City,and Zip
-e I 1 z: , ,---- -- - - --- — —
County Parcel Identification No.(PIN) l.W tQ..t 3'0 t^
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
350 field, h
(if well one is sufficient)
,5"1 3 7 N so o —Si /— I '' 22. flow
W
6.Is(are)the weIl(s): QPermanent or ❑Temporary Signature of Well Contractor Ofice24/'\44 Date
By signing this] ar.Iherebv certify that the well(s)was(were)constructed in accordance with
7.Is this,a repair to an existing well: ❑yes or o ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair.fill out brown well construction information and explain the nature of the of this record hat been provided to the well owner
-
repair under#21 rrrnarka 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 const[Uction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( Over'.in Remarks Box).You may also attach additional
drilled P if necessary.
� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (/
For multiple wells list all depths ifdii different(example-3@200-and 2@100) ( ) Submit this GW-1 within 30 days of well completion
/�t mp per the following:
10.Static water level below top of casing: CJ ( ) 24a. For All Wells: Original form to Division of Water Resources
If water level is above casing use +" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 (DWR),
11.Borehole diameter: 6"
Cm-) Pro 24b.
For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
12.Well construction method:Air Drill
gram.
(ie m cable,(Facet 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
13a.Yed(l;pm) 50 Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
I3b.Disinfection type: Sterilene Amount: 3caeS
•
Fong GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018