GW1-2022-04038_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCR
Well Contractor Name
n'ITON
2464-A
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM I TO I DIAMETER THICKNESS I MATERIAL
ft. fL in.
Company Name 3���9
2.Well Constriction Permit#: FROM I r0 DIAMETER I TRICKINESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) _ + 17,0 ft. 6 1/8 in SDR-21 JPVC
3.Well Use(check well use): ft• Z ft C'
Water Supply Well: FROM I TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public fa ft. in.
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft., ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) -
❑Irri ation ❑Webs>100,000 GPD =` 22
ZBentonita
EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Hole Plug
❑Monitoring ❑RecoveryInjection Well:
[]Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL EMPLACEMENTMEraOD
❑Aquifer Test ❑StorrnwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTI color,huMess,sai/rvck sue,eta.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
/+f ft. � ft.
4.Date Well(s)Completed: `l� Well ID# 3 ft eft• s I�
5a.Well Lo lion:
j,�. fL tvAte �- ,rn
� ft. ft. . .
ft. ft.Faoility cer Name Facility llNl(if applicab
Physi Address,City,and Zip ft. ft APR 2029
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22 CertiS n
35 0-3 `:2 a N 80p 36 /l" W
6.Is(are)the well(s): I/rmanent or ❑Temporary Signature ofCecti ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in 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 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 021 remarks section or on the back of thisform.
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: L &� (ft)
For multiple wells list all depths ifdiffdretrt(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
(B-)3 o 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfw oter level is above casing,use"+"Static water level below top of casing: Inf irrnation g � �•
Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf
11.Borehole diameter. 6n (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24c.For Water Supply and Open-Loop Geotherroal Return Wells Copy to the
(i e.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 producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterile"¢ Amount: �a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2o 1s
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