GW1--05479_Well Construction - GW1_20230821

. ••- ..vi a ant.iJUrl HE CURD(GW-11 1 For Internal Use Only:
L Well Contractor Information: ' '
Ricky Corriher _-- .. _
Well ContoMor Name FROM TO DESCRIPTION
2464-A •
/2D ft.' Cl c
• NC Well Contactor atioaNumber 3 7V 3� `•
Frank-A. Corriher&Sons Well Drilling, Inc. FROM
M TO D nuct ss 'MA-haft T
2.Nye C�onsftustiDa Permit#: 1 .✓ '1 01 • PR TT.Q2- 1X) _-:_::=1:17.-;; _ - —
Latall applies bk we11 construction pew(ie.UIC County,Sire,Variance,eta) +I it if N ft. 61/8 m_SDR-�2.11 PVC / 1
3.Well 6 Use(check well use): ti ft' 1/2 u.b 57 / , eJ c! (d-
Water Supply Welk
•
FBOM TO LD]AMErER SLOT SI7 mamas MA TSlt1AI
�Agoculhaal ❑ al/Publfc . ft. R fa
❑Geothermal(Heating/Cooling Supply) " Water Supply(single) ft. n in. —
_
• • ❑Indnshiai/Commercia1 ❑Residentiial Water Supply(shared) —_-- -
❑hrigation (]Wells>100,000 GPD �M; :::: TO MAMMAL &aMotntr-
Non-Water Supply Wen: 0 22 ft- Bentonite Hole Plug
DMoamoring ❑Recovery ft ft, .
Injection Welk •
n Aqui ❑CmoundwarerRemediation ft. ft. ,
13Aquife Storage and Recovery ' ❑Salinity Barrier •V PROM.. '.TO. .V Manua.f;i- . Eran.ACl3ffi7rMcrsoa
DAqui Test ❑Stvrmwater Drainage ft.
• ClEaperimenralTechnology ❑Subsi bore Control' ft ft. .
❑Geatitermal(ClosedLoop) ❑Tracer ` _::r is:c=.' _-; _-: _;.;r-;-
i]Cseo al(Fr+tinp/CooluogRetum) ❑Other(explain'uader#21 Remarks) FROM To C ,_m�+@.
/y�y D '� :z f3r�c(.>�J tin
4 Date Wen(S)Completed: �•J- v�„ 3 Weu IDi� )D ft' - (, ft. �(3sel4,r -"`--
e Low Kam R 4 1 e- Gsa..„4-e_..
y.-..• ,, .,_r.,
4='"Nm FaclityLW tfappllable)v 92 $ V e L '
35 Cagle 3 _ Rd /< 4'2gf.1 #G 21
C cvh a rr-iAS
COSY ParcelI on No.(PIN) �/y015OG`
Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iforell field, is sufficient) I/ 22.
350 e(' ' N80Q ._-3q- i0 W•
- g~
4,3
6.Is(are)the weit(s): 1ermaneat or ❑Temporary Signneae of r Date
By signing thisltnn,Ihereby cereP hiatthe welks)was 6veze)constructed m accordance with
7.Is tide a repair to an existing wen: ❑Yes or o ISd NCAC 02C.0100 or ISA NCAC 02C.0200 Weil Construction and that a
ff this is a,repav,fI11 out krona well construction information and aeplain the nature of the oftlds record has hems provided to the well owner.
repair under#21 mania section or en the back of this form.
23.Site diagram or additional well details:
8 For Geoprnbe/DPT or(Soled-Loop Geothermal Wells having the smme You may use the back of this page to provide additional wet en info
only 1 GW 1 is treaded Indicate TOTAL NUMBER of wells (add'See Over',in Remarks Box).You may also attach additional pages if necessary.
ccmstmction, j drilled:
24-SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: if ✓
Far mrrltrple wills list aft depthsifeirj (example-3(a 200 and 2Q100) (R) Submit this GW-1 within 30 days of well completion per the following: .
10.Static wad level below top of )•( 24a. For All Wells: Original form to Division of Water Resources (DWR),
If' level is above USE"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24h.For Injection Wells:Copy to DWR,Underground Inje�Control(TUC)
11.Borehole dnmetrs:6" Cm-)
12.Well construction method;
Air Drill
Program,1636 MSC,Raleigh,NC 27699-1636
Cu anger
rotary,cable,craw P��) bk.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.Yi (Cpm) ) Method of test Air Pitt PtOgtam,1611 MSC,Raleigh,NC 27699-I611
13b.Disatfon type:Steri lene Amoy 5 CGPs
f
Form GW-1 North Carolina Depxcrmeax ofEavaot®enral Quality-Division of water Re.^,oe¢ors
Revised 6-6-2018