GW1-2022-01209_Well Construction - GW1_20220103

9
WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
I.Well Contractor Information: \
Ricky Corriher Y
Well Contractor Name FROM ' TO DESCRIPTION
2464-A n It q0 r`' 7 ' Q/
NC Well Contractor Certification Number �3 t ;`�� ��
Frank A. Corriher & Sons Well Drilling, Inc. rAoM f DLAMETER THICKNESS MATERL L
Company Name
rt. ft. in
2.Well construction Permit#: 3 g 17 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +1 ft ft 6 1�8 1D SDR-21 PVC
3.Well Use(check well use): it. 2 Z ft 9,in• S�,
Water Supply Well:
OM TO
ft
MATERLL
S KSS❑Agricultural Vewidential
cipal/Public
❑Geothermal(Heating/Cooling Supply) Water Supply(single) U�
ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATE RLAL EM�Pl
NT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Ho
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft.❑Aquifer Recharge ❑Groundwater Remediation ft
�G. ..__
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft IL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer $ -h
. , ece9s
❑GeOthenatal FROM TO DESC O rnloy harda soil/rock(Heating(Cooling Return) ❑Other(explain under#21 Remarks) IV ft 1 0- ft M grain size,eta)
4.Date Well(s)Completed: 0 P9_a Well ID#
5a..yWell Location:
' / / �Z ft a S ft �_ a p�
n /O!.d V►� �nT l� rt fL 1 V�' v
Facility/Owner Name Faci ity ID#(if applicable) ft ft
�G Pam/ l s� ft ft
Physical Address,City,and Zip ft ft
�2 Lila 1-7 n// O g ttt�
County Parcel Identification No.(PIN)
Il r \ J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p 22.Certif cation-
35 N 80 '� 0 �� W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of C p ed ell Contractor ! Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Wo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform.
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 construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
/� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ice. 6-�— ft)
For multiple wells Jut all depths tfdiJjerent(example-3Q20000'and 2@100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: L O (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b. For Injection Wells:Copy toi DWR Underground Injection Control(IUC)
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air
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 producing over 100.000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-F T
11
r
m1 '�
13b.Disinfection e: Sterilene - Amount: � C,�;jj4_5_
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8