GW1--04678_Well Construction - GW1_20230721

- - --- ....,-a i ror internal Use
' L Well COntracter Information: •
Ricky Corriher __
-Welt Coreramorllame
•
' NC Well Contractor Certification Number J
Frank -• _
A. Corriher'& Sons Well Drilling, Inc. 2
FROM TO =�.:: n — _
Company,Name �j j fL D7ps -rgR in � DlATERLay
2.wen Conshradion Permit# . {`/ y 1Rp M - 1 �
ro
Litt all applicable Mil construction pea rite(ta InC Coconv,Tb+m D ~D R
3.Well Use(cluck well use): SD R-21 PVC
Water Supply Welk -
iculhuat bROM ® = _- -
❑,: ...al/Public ® xm«s —ny� uar ;.
DumnIR
°G7eothermal.(Heating/Cooling Supply) 4 Residential Waters l
• . pTn�"dTiaUC�metcial Supply(single) � fL
°I�tgatroa ❑Residential Water Supply(shared) ... -,,:.©®—
Novi ti °Wells>100,000 GPD FROM Tp
Supply Well: 22 R fir y•a.�niouxr "
DMonito mg °Recovery rfc Ben___ Hole Plug
alliiiimme
Injection Well:
°Aquifer Rechuge °Groundwater Remediation ft.
~ ---- - ----
StorageandRecovery I °SalinityBarier . _ FROM To �T3iIAL - - >mHiODDAquifrrTact °StormwaterDrainage z
ClExperimental Technology °Subeidntro Control• ft
Dial(Closed Loop) ❑Tracer :e.---_ r,
t7Geotb�nal(Heating/Cooling Return) °OtherFROM To
(explam'uuder#21 Remarks)
a.Date w �► ft. d r �. .� .•� :.,g am
e11(s)Completed: / /� well�# ft. .
'� Se.Well Location: ll�'� 5 ..' �
. /00 ft 34 ft 5 -". ,arc) h
Ci L al Ao�3')r �� Cto - ,
P
Pau/lily 1D#(if applicable) ft
bpi' irh/kmc k cti (A, .R w
- 1.� c. T s
PhlalAaat�,4n;rod Zip
R. '
Parcel ldencille bnNo.(P/N)
5b.Latitude and longitude degrees/minutes/seconds or decimal' r .a►e� r
•
�� Of well
field,one laHlong is
sufficient) d %� -'
35o �' 3 / t/ 80 '� /J t 22. cation
N C�- 7 — ® w G,
6.Js( e)the _
w�(s): ri�IP reraaaent or °Temporary Signanae of Wellcontactor. �� 7
signing
Date
7.Is this a repair existingwell: o �6 NC4C 02�00 NC6C Thereby cers:&02C.0200 Well the well(s)um( Sanala in as and
with
m rmearla section or arenation and esplat,the move of the ofthis record hag been Provided to the well oxeeer- nerd dtat a oopv
baaFofdeisforne. r-
repair 8 ForGeoprobe/DPT or Closed-too 23. diagram or additional well details:
p Geothermal TOTAL
Wells of the e (add'See°vet in You may use the back of this pageto provide additional well construction o
construction,drilled: '
only 1 GW-1 is needed radical, TOTALRemarks Box).You may also attach
additional/� 24.SUBMITTAL INSTRUCTIONS pages¢may.
9 Total well depth below land surface: J 1
For of al le l d t h b depute rfd et(example-3 a�200 and 2 "( ) Submit this GW-1 within 30 day
s of well completion per the following: .
10.Static water level below topof {t✓JV ( ) 24a. For���on Wells: Origin) fort to Division of Water`Resoiures (DpdR),
lfwrrterlaw!is'above '
`�`y+� g Unit,1617 MSC,Raleigh,
11.Borehole diameter:6° NC 27699-1617
(m.) 24b.For Iniection Webs Copy to DWR,Underground
Program,1636 Injection Control
�-'W�COa metitod:Air Drill
MSC,12aleigh,NC 27699-1636 �C)
li at''°tffi3'cable,daect pmh, ) 24 Forrater Wat Su and en-trio
CO.. � er health Geothermal Return Wells:Copy to the
FOR WATER SUPPLY WELLS ONLY: depart t of the county where installed •
r 24d.For Water Wells n rodn onv Over 100 000 GPD Co
13a.' �Pm) v Method of test Air Per Program, MSC,Raleigh,NC 27699-1611 pY to DWR,CCPCUA
I3b.Disinfection type:Sterilene Amour G ,�s .
Form GW-1 No Carolina
Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018