GW1--04799_Well Construction - GW1_20230721

s•a:.="•'a..t,xw i'1(U1.11VP4 KLCUKI)(GW-1) For Internal Use Only:, .
1.Weil Contractor Information:
Ricky Corriher
WellConIIaeLorName , DESCRIPTION —
•
2464 A /j
NC Well Contactor Can Number J � `� EZIIWAIIIIIIIIIIINNI
��,�
Frank A. Corriher& Sons Well Drilling, Inc. 11�..;.:;a ,rt,. N4 . -
2.Well CADBtiUCtlAIIpeTIDlt# '�Z70 -6 • -< •:�f-..t-cam=-„: ;C= `- =gym
2.Well plioabkwe•1(nPeconstructionmitP r County, �To :::. no01M:,Ys: 11 :i(ei l ." 11I.• atiAi,- --- -
u1cState,Variance,ear.) +1 � r- • 61/8 m' SDR-21 PVC
3.Well Use(check well use): " f ' aal - d
ILIMIll
Water Supply Well: ;:::, __ '
❑Agpcahmal '' r TO =lnr�r„poi• yr.
❑ • blic • h ft �� ylFvre:�as:t:wr.a:�� blplBRlny
❑Geothermal(Heating/Cooling Supply) ).-;;• :- Water Supply(single) in.
• ❑Indu ial/Commercial ft. it • 'n
❑Residential Water.Supply(shared) -1:7.-.--^.- - - � '- •
—
Olnigation ❑Wells>100,000 GPD i�s'1111116.11:;.v4,.ae.11111111,0,.ww:T.,:..,-.;
Non-Water Supply Well: r r; .,w:c.;,f 3,�.;;.1;,; i
0 22 R Bentnriite Hole Plug
[Monitoring ❑Recovery ft. ft
Injection Well:
wen:
ft. ft -
❑Agmfea e , ❑Groundwater Remediation -
❑Aqut r Storage and Recovery ❑Salinity Barrier " :' g,. ., -- ----- ---------
❑ Test M-e''' Er u-- AAm. - _,74-irks;=,-;;;.,,}aaT
T ❑Stormwater Drainage , ft ft.
❑Experimental Technology ' ❑Subcirl,mre Control' ft
OGeothermal(Closed Loop) ❑Tracer. - --?. >_- _- - _ - --_ ----------- --
OGeothe mat(Heating/Cooling Return) ❑Other(exolaia'imder#21 Remarks) '�'.!r'� 4 -t i
4.Date Well(s)Completled:�1'.9a � Well ID# INIEll ft. / =
Sa.Well on: N - Ma 4 k - - -
Q &n p�„ ��r R a _
IMilFacility/owner Name - acility ID#(rf lr ?) « i f'
'6?' 9 �� roaidi i <clef/ `e4-50 ivti gel Rmimmiiimaiin •
Co®ty Parcel Idenrifirarinn No.(PIN)
' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one tat/long is sufficient) /R /
35G� � 3 �/ • N 80(J •`�/ �� // 22.Ce ' tioa:
4/ �orar • ., ,z, . . ---c2ob' ,2-3 '
Si ofCectiS WellConiracto �
Date
6.Is(are)the wen(s): [BPeraaneat or ❑T
By signing this form,l hereby cei*that the xvl!(s)ees(were)constructed in oc anic:ce with
7- this a repair to an existing well: ❑Yes or O ISA NCAC 02C_0100 or 15,4 NCAC 02C.0200 Well Corestructior Standards and that a
Ifthis is a repay,fit!out brown well construction informe:ion card explain the nave of the ofdt+s record has been provided to the'well punter.
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 conStnuxioa info
drilled:
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells , (add'See Ove?in Remarks Box).You may also attach additionalpages if necessary.
24.SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface:xpll tple s List ail deptlu rfdifferent(ercanple-3 a�Z00'card 2 aQ100� ( ) -
Submit this GW-1.within 30 days of well completion per the following: .
For mrd
•
10.Static water level below top of casing: 7"O ( ) For All Wells: Original form to Division of Water Resources (DWR
!fw level is abort casing +^ Information Pmeessmg Unit,1617 MSC,Raleigh,NC 27699-1617 ),
11.Borehole diameter:6c' �m-) \ 24b.For Injection Wells:Copy to;DRrR,Un
derground Injection Control(IUC).
- 12-Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(ie auger,rotary,cable,daect 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
I3a'Yield(rpm) l / Method of AI r • Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type;Sterilene Amount y tiles .
•
•
Form GW-1
North Carolina Deparanem of Envinoamenral Quality-Division of Water Resources
. Revised 6 6 20I8