GW1-2022-03700_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A 3es ft. 321"t
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
2.Well Construction Permit#: -3 a/ n FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well eonstructionpermits(i.e.UIC,County,State.Variance,etc.) t1 ft. ft. 6 1/8 in. SDR-21 PVC
3.Well Use(check well use): 4'3 ft. J in. G Lt
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
❑Agricultural J,,id�
ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ntial Water Supply(single)
ft. I ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) mom
> GkIO
❑Irri ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft. Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
heab.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ff• ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer h
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIMO color, rdness soLrock size,etc
O ft. � ft. pp Y
4.Date Well(s)Completed Well ID# JV It. ft
5a.yy 11 Location: ) y-- ft. 3,*ft' U r
=� //V4, ft. ft.
Facility/O
w
�ner Name �7 a Facility 1D9(if apptfic�abll/� ft. ft.
CJ 2�Q�r� CP L�F���% �' ii,ek C- �. ft. ft.
Physical ddress,City,and Zip �J v ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ' 22.:C:e�rtirin.:,
35 �'t T` N 800-J q 3 7 w n
6.Is(are)the well(s): 6ezii.ent or ❑Temporary Signature ofCertifip&Well 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 I5A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthis 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,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-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: (ft.)
for multiple wells list all depths ifdierent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
3 O 24a. For All Wells: Original form to Division of Water Resources (DWR),
lJwater level is above casing,use
f Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"*"
11.Borehole diameter: 6" (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method-Air Drill 1Y and Program,1636 MSC,Raleigh,NC 27 24c.For Water Supp 699-1636
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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield m / AIr Pennit Program,1611 MSC,Raleigh',NC 27699-1611
(gp ) Method of test
:Air
Disinfection type: Stenlene Amount:
MAR 2 9 202?
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018