GW1-2022-01598_Well Construction - GW1_20220204

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
4 i
Ricky Corriher -
FROM I TO DESCRIPTION.
Well Contractor Name ft. 1° tt. a,
2464-A
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM I TO DIAMETER;in. THICKNESS MATERIAL
ft. ft.
Company Name .-/ O -
/ FROM .TO --- DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: JJJ
List all applicable well construction permits i.e.UIC,County,State,Variance,etc.) +1 ft. ft• 6 /H in' SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tL ft. in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared)
❑Im ation ❑Wells>100,000GPD FROM TO MATERI I EMPIACEMENrmrmoD&AMOUNT
Non-Water Supply Well: 0 ft' 22 it Bentonte Hole Plug
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
11 IN,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer v
FROM TO DESCRIPTION br,haideess,sail/rock size,ere.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) D ft. 7d R.
4.Date Well(s)Completed: r Well ID# 2 0 ft. ft. ff-o c
5a.Well Loca'on:
Ca/
Facility/Owner Name / Facility lD#(if app ticable)' ft. ft.
IL
Physica1J,�gdress,City,and
Zip
/_ ft. I
l O
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi lion•
35 N 80 W l-l -22
Signature of C t
6.LS(are)the well(s): l9Permanent or ❑Temporary ell Contractor Date
(
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �o 15A NCAC 02C.0100 or 15A NCAC 01C.0200 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:
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-I 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: OE (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ti•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells -ducing over 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: z C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised"-2018