GW1--06275_Well Construction - GW1_20230926

. ••......•a.v 'nut-i iui'KECUR D(GW-1) 1 For Internal Use Only:
L Well Contractor Information: '
Ricky Corriher . _
WellContactcrNa� io_- - D»CRWnON ----- ------ --
Well �.�0•
�` �f
NC WeIICoa�ador Certification Number
fi ��
Frank A. Corriher&Sons Well Drilling, Inc. Vm� —~sa„ ;;a ii,;. --i—T - .
. Company Name ft. m
2.Rid'Construction Permit#: f�I r• a l z =` l'o �,, . 'V A EI ( .:. ----
Lim all tgplicabkwell construction p arc.Cow,State,Variance,ere.) +1 ft. Y1/.ft' 6118 m SDR-21 PVC
3.Well Use(deck well use): ,c.!Y ft i1,_; 66' f- - 'a. "7�
:•_,_..z=2.-rr.ff.,-,..- •titIturalupply Well:
FRDM
Clbitmicipal/Public . ft. ft. in.
OGeothemrat(Heating/Cooling Supply) u'tesideniial Water Supply(single) it M. _--
OluchistrialCommercial DResidentiai Water Supply(shared) .
Dhugatroa OWells>100,000 GPD .T hv.vIxar,Mini-,.;.ywr.'r...nai 1c:.iti4:1,91:11 a
Non-Water SandyWes` 0 it 22 Bentonite Hole Plug
CIMonitcuing DRecovgy ft. ft. -
Injection Went
t7GrormdwaterRemediatioa____
AOAquifr Storage and Recovery DSalmily Bonier i fE�' ' - -- - - -
�AQn1�Test (].SfDi4 ter Drainage
ft. tL �:,•:��w[r r..�.,�i,-.�:y�:���i'
' ClExperimental Technology DSnheirir•nr o Control. ft ft.
DGeotbe�l(Closed Loop) =racer , --_. =_- __ -
-.. •- -
aC at(Etxbng/C`ooli Return) OOiber(eaplain'tmder#21Remarks) ��I' ,�• r-.-3... . -T-r_�'
v ft. mu ingmwerawangairA
4.Date Well(s)_ciagtleted: 9--/3 -23 Well 1D# - --e.)i iG,z. it A, god ho, / .- 1.,
Sa.Vf• F_-,:'ton: 4/4WJWAIIIIIEREMIIIIIII
ft.
c ty/p g f.
Facility ID#(if applicable)
- /OR90 -l�_1�t2 44 god( ,/ ft. _ .
Physical Address,(may, ft.
County Parcel IdeadfcationNo.(PIN)
Latitude tuugitnde 1n degrees/minutes/seconds or decimal degrees:
fiong
gs ) 22. ' n:
35Q3q/25 ,/ N 800.--a Yr /t e/ w ileA,Itc,4
6 Is(are)the we$(sr or OTemporary Signature of Well Contractor Dna-
7.Is this er existing Bvsigning this form,Ihereby certify that the re-11(s)wazs(were)constructed m accordance with
repair in anwell: DYes or l 154 NC IC 02C.0100 or 156 NC6CO2C.0200 Well Construe*cn Standards and that a
Ifthis is a repair,fill out brown well construction i bnnerian anti explain the naive of the ofthis record har bee,,Fmnfered to the%cif oumer.
repair tinder421 remarks-section or cc the back of this form.
23.Site diagram or additional well det il=
8.For GeoprobePTPT or Closed-Loop Geothermal Wells having the same • You may use the back of this page to provide additional well censunCrion ittfo
condril only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet.ia Remarks Box).You may also attack additi�lpa�if may.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: •
Far multiple wells dstaII depda if u(example-3@Zo0nnard 2(a)100) Submit this GW-1 within 30 days of well completion per ihefollowing: .
1Q Static water level below top of rasing: Z5 .( ) m- For Ail Wells: Original form to Division of Water Resources (DWR),
1f Jewel isabove�+r+&use•"+" Tnfnrafian Processing—Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells:Copy to DWR,Underground Injection Control(1UC).
11.Borehole diameter:6" Cam)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636 • r iZ construction ed. 24c.For Water Supply and Open-Loop Geotltetmah Return Wellsi Copy to the
(u auger,rotary,cable,three 1?ush,exc.)
county envy health department of the comity where installed.
FOR WATER SUPPLY WELLS ONLY:
(,� 24d.For Water Wells producing over 100,000 CPI):Copy to DWR,CCPCUA
13a.Yield(gpm) t" Method of test Air Permit Program,1611 MSC,Raleigh,NC 27699-1611;
13b.Disinfection type:Sterilene Amoy 3 err_S
Form GW-1 North Carolina Departure=of Environmental Quality-Division of Water Resources
Revised 6 6?A18