GW1--04441_Well Construction - GW1_20230710

r„.u.a••,1.V1.o a/cut,1AM RECORD (GW-1)
For Internal Use Only:
1.Well Contractor Information: •
Ricky Corriher
Well Co � t1 —
FEMIIIIIIMIIIIIIIIIIIIIIIM
2464 ANClar To DESCRIPTIO T —_— —
NC Well Contractor Certification Number FRORO:2-e'3� S'• t r
Frank A. Corriher& Sons Well Drilling, Inc.
M TO �,lr�„, a`a S" . �MATERIm ,
Company Name N- ft m
r Ps;���.. ?:. l,.,.LT}�
2.Well Construction Permit#: ��J6 i FROM TO ES --.
List all applicable Hell constructionpemits(Le.UIC,County State,Variance,etc.) +1 1t 6 1/8 in-AMETER THICKNESS
SD R-21 PVC
3.Well Use(check well use): ` 9
Water Supply Well: �6Yr—,7 ftMilI
FROM TO
OAgncultural O al/Public DIMMER. �yra,ryr� MATERIAL—
ft ft in.
OGeothennal(Heatatg/Cooling Supply) }'dResidential Water Supply(single) ft
• Olndusirial/Commercial ft. in.
OResidential Water Supply(shared) _
Olrrigation OWells>100,000 GPD -FROM TO ` •
Non-Water Supply Well: � ` Martrunl �a,i� :�..� 1+"ar a u�,z�t ulo
OMonitoring• ORecov 0 ' 22 � Bentonite Hole Plug
� ft —
j Inection Well: •
ft. ft Injection
°Aquifer Recharge ❑Groundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier s TO .y-. "- '_
MATERIAL i�";,IiATr%w�a�ar,.,ra.?:fa)t OAqui>Er Test ❑Srormwater Drainage f. ft. a
OExperimental Technology OSubsidence Control' ft. ft
OGeothermal(Closed Loop) OTracer a €- %Y _- —'
::s
OGeothemtal(Heating/Cooling Retain) OOther(explain'under#21 Remarks) ®�={ . ' n"7f. rr-ar ,��'
ft IrallilITL=ainffawm....1
4.Date Well(s)Completed-3/`�j Well m# led ft d ft
) , 5a.•-W�-ell Location:
kJ JentiJ -Ye flit/-o imp' o3-6.
c
Iminsmaniin
Fac'' Owmr Name Facility (if applicable)
ft ft. - "_,.
)� CO%1'e// z(1d7,..�o t f� f. ft.Phys Address,City,and Zip / / ft. }
V/b9 ii,v2
A
County J Parcel Identification No.(PIN) iJ{a �L�
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
_ _(if well Said, is sufficient)
35 3 �I f 1 N O 0 Q o Q `-3 / "/ 22.Ce ' tion:
v, Li W
���� --- Z
6.Is(are)the well(,). permanent or OTemporary Signature of CcgiS'�d Well Cor /
Date
Bt+signing this form,l hereby certify that the well(s)was(were)constructed in accordance Hith
7.Is this a repair to an existing well: DYes or 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Weil Construction Standards and that a copy
Ifthis 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 ny.
chilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ig. ft
For multiple welts list all depths ifdifferent(example-3Q200'and 2(a�100) ( ) Submit this GW-1 within 30 days of well completion per the following•
10.Static water level below top of casing: 3 0 ( ) 24a. For All Wells: Original form to Division of Water Reso If water level is above casing use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 urces � )'
246.For Injection Wells:Copy to DWR,Underground Injection Control
12-Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636 (NC)'
11.Borehole diameter:6" (in-)
(i e.auger,rotary,cable,d¢act push,etc.) 24c.For Water and Open-Loop Geothermal Return Wells:Co to
county environmentalental health department of the county where the
FOR WATER SUPPLY WELLS ONLY: � �
2441.For W Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) /5 Method of best Air gram,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Sterilene Amount: p , ,
Forst GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018