GW1-2022-03701_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 �l� ft. ��� fs�
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TD DIAMETER THICXNM MATERIAL
ft. ft.
Company Name n -
2.Well Construction Permit#: ✓` FROM ;3ft-
AMETER THiCtINFSS MATERIAL
List all applicable well construct(onpermitsi.e.U1C,Counry,State.Yariaxe,etc.) t� ft /$ '"' SDR-Z1 PVC.
3.Well Use(check well use): v ft--
�in. r
Water Supply Well: FROM ETER SLOTSTLE THICRNE S MATERIAL
❑AgriLvltural ❑ cipal/Public ftin;OGeothermal(Heating/Cooling Supply) esldential Water Supply(single) ft, in.
❑lndustnaUCommercial OResidential Water Supply(shared) HMWN�� ON
ClIrrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O 22 ft- Bentonite Hole Plug
❑Monitoring ORecovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPIL ACEMENr METHOD
OAquifer Test OStormwater Drainage ft. ft
OExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer -
❑Geothetmal(Heating/Cooling Return ❑Other(explain under#21 Remarks FROM TO DESCRWnON color,hardness,soil sim,etc
O ft �'O " � �w
4.Date Well(s)Completed�aa-a'0 Well ID# (7 ft. Q to /, V v C
5a.Well Location: d ft o 3 ft• S L C
t an �t �ee�L�a GSA u-t° ti
Facility/Owner Name F�'�`ty R(if applicable ft ft.
O 'eC/
w/G/1 r tL ft
Physicv�ddress,City,and Zip
Il D►tia/I V,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one la ong is sufficient) /' l i/ 22.Certify ni
35p?5 Q N 80© 33 W
6.Ls(are)the well(s): 0111—'anent or ❑Tempora�o/
Signature of Certifi 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 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 921 remarks section or on the back ofthis 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled' // 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /4C/ (ft)
For multiple wells list all depths ifdii ferent(example-3©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: /S (R) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
(f water level is above casing,use
11.Borehole diameter. 6" (lo) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC 37699-1636
12 Well construction method:AI r Drill
24c.For Water Supply and Open=Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) coup environmental health dep
artment partment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producjn¢over 100,000 GPD:Co to D
I, Air Permit Program,1611 MSC,Raleigh,NC 20-701611 Copy DWR,CCPCUA
13a.Yield(gpm) �✓ Method of test:
Air
Disinfection type: Sterllene Amount: tnQ p :� h
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources MAR 2 9 2oatc.d 6-6-2018