GW1-2022-01210_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
PROM I1'O DESC.RIP,TIjON
Well Contractor Nam �W % !?at d0.
2464-A ft. ft
NC Well Contractor Certification Number - —
Frank A. Corriher& Sons Well Drilling, Inc. PROM TO DIAMETER THICKNESS MATERIAL
ft
Company Name � /O �
2.Well Construction Permit#: {(f_ l/�J J'7 FROM TO DIAMtTER T®CKNESs MATERIAL
List all applicable well construction permits(I.e.UIC,County.State,variance,etc.) +1 H � ft 6 1/8 ID SDR-21 PVC.
3.Well Use(check well use): �' It:
Er ' tt 4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural �❑ cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) 'L�JResidential Water Supply(single) fL ft in
❑ludushial/Commercial ❑Residential Water Supply(shared)
Fe
' n ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
er Supply Well: 0 tt 22 ft Bentonite Hole Plug
ring ❑Recovery !t ft.
Well: ft ft
\ Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
' N ❑Aquifer Test ❑Stormwater Drainage it it
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,soWroek sae,etc
+ ❑Geothermal(Heating/Cooling Return). ❑Other(explain under#21 Remarks) ft 3v ft ra W vV L
4.Date Well(s)Completed: Well ID# 3� ft cf� ft ft. !J�
Sa.Well Lofation: ` � Y
�t l.�Srl c�e�rY ft ft jD j e_ !�
Facility/Owner Name F ility ID#(if applicable)
ft it
1 WW�r/�a� f/ c�l�a Gteue fL ft 3 2fl -
Physical Address,City,and Zip ft. ft
County Parcel Identification No.(PIN) �I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) �� 22.Certification:
35 0 i N 80 d -3 7 ` 5 w f
6.Is(are)the well(s): ermaneut or ❑Temporary Signature of ed ell Contractor Date
W .
By signing this form,I hereby cerdfv that the"11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or WNo 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a COPY
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of thin record has been provided to the well owner.
42
repair under#21 remarks section or on the back of this form.
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 1 GW-I is needed. Indicate TOTAL NUMBER of we lls (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: / v_T (ft)
For multiple wells list all depths ifdtjjerenr(example-3(3a 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
if xnter level is above casing,use'.+Static water level below top of casing: O (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ij •'
6" 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.)
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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinE over 100,000 GPD:Co to D
13a.Yield(gpm) D Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy WR'CCPCUA
13b.Disinfection type: Sterilene Amount: 02 CA
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018