GW1-2022-00907_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name �t4V W it- ` y y
2464-A ` 4ft. cJ
CV
NC Well Contractor Certification Number —
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER TMCKNESS MATERIAL
ft. fL in.
Company Name
VQ ' FROM TO DIAMETER THICKNESS MATRRTsi.
2.Well Construction Permit#:
List all applicable weU construction permits(i.e.UIC,County,State,variance,etc.) +1 fL l - fL 6/1/8 'a SDR-21 PVC
3.Well Use(check well use): ft � (A ri m. �+e ¢ I/
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ❑ crpal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) M ft. in.
❑ludust Wcommercial OResidential Water Supply(shared)
Ohri ation ❑Wells>100,000 GPD FROM TO MATERL4 EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 fL 22 ft- Bentonite Hole Plug
❑Monitoring ORecovery fL fL
Injection well: fL fL
OA.quifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAI EMPLACEMENT•METHOD
OAquifer Test ❑Stormwater Drainage tL ft.
❑Experimental Technology ❑Subsidence Control fL fL
OGeothermal(Closed Loop)
❑Tracer
❑Geothermal(Heating/Cooling.Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,haran soillroek Sim,etc
Q fL �p 0 tL &,- � "'
4.Date Well(s)Completed: �� / Well ID# 6 1) fL 00 ft- c' ' V I
52. /
Well Location: U L,2 J /c"
D04e7 p Om-e Sa IC'S
Facili /Owner NaAe
Facility ID#(if applicable) fL tt
Phys' Address,City,and Z' fL ft JAN n'
County Parcel Identification No.(PIN) d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fold,one lat/long is sufficient) / 22.Ce cation:
3503L/ N 800- �f - ��' W
6.Is(are)the well(s): armament or ❑Temporary Signature of ed Well Contractor Date
By signing this form,I herebv certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an eidsting well: ❑Yes or (N0 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.0100 Well Construction Standards and that a COPY
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f) Submit this GW-I within 30 days of well completion per the following:
For multiple wens fist all depths if different(example-3 c@200'and 2@100�
3 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If inter level is above casing,use
6" 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (n-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin¢over 100,000 GPD:Copy to DWR,CCPCUA
t/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) (� Method of test:Air
r
1-7
13b.Disinfection type: Sterjlene Amount: �a,��
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6b-201$