GW1--04442_Well Construction - GW1_20230710

._-- .....••,=LW .Levil nr,�.utcU(tiW-1) For]ntemal Use Only:
1.Wen Contractor Information:
Ricky Corriher
2464 q• Well Can/matte Name L;
FROM .• -- Din -
Ma l�j
NC Well Central toe Can Number ft.
Frank _==.i —
A. Corriher&Sons Well Drilling, Inc. —>-ROM `TO ate.—= -- °
Company Name 4,�� ft ®®=~ i�rni.
2.Well co 39/5 C> FROM
- ..
construction Permit# FROM DIAMl
em List all applicable well construction permits(i.e.NC County State,Variance etc.) +1 ft Tatman mamma,
—-_
L/ 61/8` m SDR-21
3.Wen Use(check well use):
Water steely Well:
Li 41 W 6 �-
FROM
cumtral • �.. blic To ohoo ER 7,1 , .�=i TSIC i&3 _ MATERIAL'
ft. f. in. MM.
° (HPatinp/Coolmg supply) . �:. tial water supply(single)
• Ohx ial/Commetuiain — —
❑Resideatiat Water Supply(shared) -•-..�—.,,,-
Obligation °Wells>100,000 GPD IBM= To IL,r -�t�
Non-water --- c snr 00 i UN
amply Well: 0 ft 22 ft. Bentonite Hole Plug
OMonitoffig - ❑Recovery f. ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation —
❑Aqu�u Stoage and Recovery °Salinity Bather PROar' --= L -- - - -
AquiSerTest OStoznwater sea
❑ r-ate :r :.
Drainage
r tt ft.
ClExperimerdal Technology DSubcidmre Control' ,ft.
' , ❑Geot canal(Closed Loop) OTiacer ;r,,-;•:r: -;_ __ --- -------__
Q- tbeanal(Heatmg/Coolmg Reomm) .°Other(explaia'under#21 Rematis) �''D'•" e" ••+ _—
�� a .� :•rar,ea.
-7✓ - vd
4.Date W -� ��•�e11(s)Completed: well ID# ft ��(';�`i
Sa.w Location: �/" iy u� •
or/ s �2•et. ,i /S/2 .
F�'tO C ^ Facility (if k) ft ft. .,.. :.,...
Address,is
City,andft ff.
County Parcel Idelee:wa, No.(PEN) -
111111111111111111111111111
Q Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
('dwell field,one�is su dent 22.7catio
wete...ie,,,t/../-4,ls(are)the well(,): @Ip rermanent or °Temporary SiSignature of Well '����Date
6.
7.Is this a repair to an existing well: ❑Yes or By signing rhisform,I hereby certify that the wall(s)was(were)cons g o ISANC.ACO2C.0100orISANCACO2C.0200Well �m O
Ifthis is a treat:fill out brawn wall construction information and erplcin the nature ofthe ofthis record has beery provided to the well owner. Construction Standards and that a copy
'repair under#21 tsnarlec section or m 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 boa info
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also a additional
construction if necessary.
- 3 5 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l7
Formaltytk was list all depthsifdiffamt(example-3Q200'and 1�1001 ( ) Submit this GW-1 within 30 days of well completion
H.Static water level below top of casing: 9O 24a. For All Wells: Original per the Resources
(ft,) form to Division of Water Resouces�' level u those easing Use-+� °matron bores g Unit,1617 MSC,Raleigh,NC 27699-1617 (DWR),
11.Borehole diameter!6" ( t.) 24b.For Injection Wells Copy to DWR,Underground
Program,1636 MSC,Raleigh,NC 27699-1636 Injection Control(IUC).
12.Well hod:Air Drill
(i 0 Y.able,dtneet push,et) 24c.For Water Supply and Ones-Loon Geothermal Return Wells.
cow environmental health department of the county where installed
Copy to the
FOR WATER SUPPLY WELLS ONLY:
Permit24d.For Yield Program,ater Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
tea' (gpm) Method of best:Air 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection types Sterilene Amami: 9©tar s. '
Form GW 1 North Carolina
Department of Environmental Quality-Division of water Resources
Revised 6-6-2018
i