GW1-2022-04034_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIMON
2464-A
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. MOM TO Dr R Truclavrss M,,,ERL41
Compaq Name ft 1n.
2.Well Construction Permit#:33.E VROM TD
DIAMETER TAICKNFSS Ids[all applicable well consouct[onpermits(t.e.UIC,County,State.Variance,etc.) +1 & a & 6 1/8 1n. MATERIAL
DR-21 PVC
3.Well Use(check well use): `LV fL %
Water Supply Well:
/❑Agricultural ft.FROM TO ft. DIAMETER SLOTSIZE 7MCKNESS MATERIAL
❑Iy�micipal/Public in.
❑Geothermal(Heating/Cooling Supply) ;Residential Water Supply(single) ft ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared)
❑hTi 'on ❑Wells>100,000 GPD FROM TO MATEnIL EMPLACEMENT MEfAQD&AMOUNT
Non-Water Supply Well: O 22 ft Bentonite - - Hole Plug
❑Monitoring ❑Recovery fL
Injection Wen:
❑A er Rec ft ft
qif hie ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPi ACEMFNl METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑EXPerimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer
❑Geothemml(Reating/Cooling Return) ❑other(explain under 921 Remarks) FROM
f To6 R DES(7rrYRON wb e,rdaesr sov em
4.Date Well(s)Completed ell Ii)# f� D ft
n
5a.Well Location: Z-C % ft S - - �
l.4rew of WVP1*la09 o �f`
Facility/Owner Name Facility ID#(if applieab1V jl' ft- fL
dG /7 )__fL
Physical Address,Cit3;and Zip fL ft.
311011 202?
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlo19 is sufficient) 21 Certifi u
356,25y �� N 8Oo—3 -/-3 / w l
6.Ware)the well(s): f�rmanent or ❑Temporary s;Snamte of Cettifi ell Contractor
Date
By s[gning this form•1 hereby certify that the wel()was(were)constructed rn accordance with
7.Is this a repair to an existing well: ❑Yes or O 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and[hot a copy
If rhrs is a repair,fill out known well construction information and explain the nature of the ofthrs record has been provided to the welt owner.
repair under bltremarla section or on the back of this form.
23.Site diagram or additional well details:
S.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 Over in Remarks Box)-You may also attach additional pages if necessary-
9.Total well depth below land surface drilled:
0� 24.SUBMITTAL INSTRUCTIONS
: ft
For muhtple wells Hsi oil depda rfdrfferent(example-3@20`0and 2@ 100) ( ) Submit this GW-1 within 30 days of welt completion per the following:
10.Static water level below top of casing: J (fL) 24a• For All Wells: Original form to Division of Water Resources (DWR),
lfwaterlevel is above caring,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6. (1) 24b.For Iaieetioo Wens:Copy to DWR,Underground Injection Control(TUC)
12.Well construction metiiod:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger,rotary,cable direct push etc.) 24c For Water Supply and Oxen=Loon Geothermal Return Welts Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells nroducin>: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: Stenlene Amount-. CA
Form GW-1 North Carolina Deparnnew of Fsivironmenral Quality-Division of Water Resources)
Revised 6-(i-2018
i
i
i
' I
I