GW1--05704_Well Construction - GW1_20230905

COI Internal Use Only:
L Well Contractor Information: •
__Ricky Corriher
• "Wel[Cont�LorName • IEMannui 10-�-c. DESCRIPTION _
2464 A •
t: — —
iimaNC well contractor C cation Number I ft
Frank A. _ , v
Corriher& Sons Well Drilling, Inc. y`-
���ro �."Dy; -- -- -
CompanyName iL ��'N• •� MATERW
, �
�j I. in.
2.Well Construction Permit#: p�._ / FRom To -List all �-
applreabkisell construction permits(Ise.UK County,State,Variance,etc.) . +1 it 6 1,8 im
3.Well Use(check well use): t SD R-21 PVC
nWeater,�suuppl'y Welk - •
• _ MU ' � '! � .f�---Q�'/�
❑Ag icu14ua1 ��1 To .ti rm1;7 Y r:t]11y L/ci r/-
•❑ al/Public �t=`bIp
• fL ft. in.
❑Geothermal(Heating/Cooling Supply) ' Water Supply(single)
❑lndustzial/Commercial ❑Residential Water Supply(shared) =:n s- • - 'm1 —
Olirigation '❑Wells>100,000 GPD To- . L-c Y�:I . •
NOn-Water Supply Welt �lsl���N:..,:.:,r. -,Y:n,2-�:�,l:�b ,i
0 22 :ti Bentonite Hole Plug
❑Mg ❑Recovery ft.Injection Welk
Wen:
Qj ❑ er Recharge ❑Groundwater Remediation
❑AQmf�Storage and Recovery OSalinity Barrier = ,- - -t _•- ? ;=.y R= - - • - =- • --
❑AquifesTest J '�' �Y<seraotar :�,,',,+wrN,.:IN, %,4 O),a
❑StormwaterDrainage•
_ft. ft.
❑ExpeIImentalTechnology ❑Subaidear-PControl. • ft.
❑Geotht�aal(Closed Loop) ❑Tracer ,, r;=--_ - r;;I r.. ..: _ _ __ ---.._-..._--,.--
:•r. _
❑C othetmal(Head cooImgRenna) DOdu3(e:cplain'tmder#21 Remarks) Magi©Il • aMP..•^-,L-.z__ -�-_-__
IMMIEM
4.Date We1t(s)Completed: - / v�3 Well 1B#
5a.Wen Location: EBILIIMILIIIIIr
cf).0 C.r ''''' ti
Facility/OwnerName Facility Mit(if applicable) ft -ft.
ct9 9g Ba.fne/A gd (,,,,J� deco 7 ft. ft. 111Eimsnmummin
(:)3
l.)
Parcel Identification No.(PIN) —
7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: l- —Cv' 'JG
(if well field,one s s�cient
35o,3g,0�,/ , )N 800 �- J�•I 22. - o
/ W tea 7 31 023 6 Is(are)the weH(ar L rermanent or ❑Tempozary \ Signature of Cr •
Ihae
7.Is this a repair to an Welk Bvsigrdngthisform.!hereby cervfv that ihe'xell(s)ens(were)constructed in accordance with
JJ out mnxeseeion in rnwtion and oIsthis record has beA NCAC 02C 0 or ISM d go Dwell ow 0 Well Construction Stands and that a copy
repaIftldi is a th ezptaiit the nature of f been provided ro the well owner
repay wider#2!ron�ks section or on the baekofthisform
23.Site diagram or additional well details: •
construction info
Yon may use the back of this page to provide additional well c '-
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same o oonctruction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet.m Remarks Box).You may also attach additional pagesif ;.
drilled ,, �✓ - necess
t/ / �i 24.SUBMTiTAL INSTRUCTIONS
9.Total well depth below land surface: (�--� i For multiple' list all depths ifdBoru(exmnple-3@2000and 2®1001
( ) Submit this GW-1 within 30 days Of well completion mp per the following_
• 10.Static water level below topof /y� i 24a. For All Wells: Ori ' t (DWR),
casing: V groat form to Division of Water Resources
1f" '� (fL) lnfarmation Processing Unit, MSC,Raleigh,NC 27699-1617
casing use-+"
11.Borehole die' meter:6" 'On-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control
Program,1636 MSC,Raleigh,NC 27699-1636
12. �C)'
Well construction method:Air Drill
auger,misty,cable,dmxt push,ens) 24c,For Water Supply and Open-I U p Geothermal Return.Wells:Copy to the
COunty environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: I'
} 24d_For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(lpm) 1S Method of test AI r Permit Program,1611 MSC,Raleigh,INC 27699-1611
13b.Disinfection type:Sterilene - Amami: C��9
- I .
•
Form GW-1 North Carolina
Decorum=of Emiiromaentar Quality-Division of Water Resources , Revised 6-6-2018
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