GW1-2022-03161_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name / w /3®ft
2464-A
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM ft. To ft. DIAMETER
DIAMETER THICKNESS MATERIAL w
�3 1/ �]
Company Name ' / /
_ .
ss--
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) -F 1 ft. J'W ft. 6 1/8 in. SD R-21 PVC
3.Well Use(check well use): ft. �t� k fain. ! U
Water Supply Well: FROM TO DIAMETER 11 SLOTSSIZE THICKNESS MATERIAL
❑Agricultural eesi;ential
cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) g fe. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared)
GAO_
Olrri ation ❑Wells>100,000 GPD FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 e• Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _
- d�a "lcab
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. fe.
❑Geothermal(Closed Loop) OTracer ODD ditiona L
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPr10 color,hardness,soi/tocktymn sine,etc
�`{� O ft' � ft. J
4.Date Well(s)Completed:• �' Well ID# 5-07 ft. g6l ic. J„r, .�
Sa.Well Location:
'� ft. ft• Y" A OG
s5'>�S'i/o ne yer le6,�P�s s�ft. �-{t. -fe G
Facility/Owner Name
Q Facility 1D#(if applicab ) fL ft.
3 fL ft
Phyzaldress,City,and Zip ^� / -7a. n•
k_a� Jt�� /,40 V U 7
q 9
County Parcel Identification No.(PIN) C 0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Id one�at/longis�ufficient) 80� ��/ ` 1 22.Certift y�y
Uri
3 if � �a R
N W
6.Is(are)the well(S): ermanent or ❑Temporary Signature of CertifiodVell Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 64/0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
!f 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 N.11 remarks section or on the back ojthis 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d (ft.)
For multiple wells list all depths ijdtfferent(example-3 rQr 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
go24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"*"Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lj
11.Borehole diameter: 6n (in) 24b.For Injection Wells:Copy to D,WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:J41 r DTI I I 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 -ducine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) O Method of test:
AI r Permit Program,1611 MSC,Raleigh,NC 27699-]611
131b.Disinfection type: Sterllene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018