GW1-2022-03698_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -- -
FROM TO DESCRUMON
Well Contractor Name z ft. 9zet
2464-A CL
NC Well Contactor Certification Number
5111!T
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name � �i�O � _
2.Well Construction Permit#: /� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) t1 R. i6 ft. 6 1/8 i" SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑M i.ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R. R. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) l G O-
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 R. 22 R Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENCMETHOD
❑Aquifer Test ❑Stormwater Drainage fe. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer d._ h
❑ 'n Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIMON color,hardness,soiltrock sin,eta
fL O ft.
4,Date Well(s)Completed: Well ID# ' ft. s-D ft.
S-tj ft. 61
Sa Well Location: -7G/ ft.
7v ft• �2 ft.
Facility/Owner Name acility,1D#/(if applicably&IZ1 9-22•
er
G-AeeI7
Phys;iJ Address,City,and Zip �— R. ft.
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is suffic ient) ( 22.Certifi g�
35C3 ` N 80p_3n - 13 W
6.Is(are)the well(sp ermanent or ❑TemporaVo
Signature ofCertifi ell Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.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 P21 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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled: �{re 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: )40 (ft)
Formultiple wells list all depths ifdii fereni(example-3(a)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),
10.Static water level below top of casing: (B•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!'water level is above casing,use ••
11.Borehole diameter: 6" (in,) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill 24c.For Water Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over.lQ0,M00 GPD;Copy to DWR,CCPCUA
Air Permit Program, MSC,Ral igh;NC27699-1611(:. I
13a.Yield(gpm) Method of test:
13b.Disinfection type. Sterllene Amount: -7 CMS MAR 2 9 2021-i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I ,:•..-.�-�� � _ vrsed 6-6-2018
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