GW1-2022-04048_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIEMON
Well Connector Name
2464-A ft IZ
ft. ft.
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc.; FROM TO DIAN=R THICKNESS MATERIAL
ft. ft. in.
Company Name cnC1y
�p ��j/ _
2.Well Construction Permit#:�v ' /i / FROM T TO DIAMETER THICKNESS MATERIAL
-List all applicable well construction permits(�nry,State,Variance,etc.) +1 ft / ft' 6 1/8 in' SDR-21 PVC,
3.Well Use(check well use): ft f fL &S`/�/in.
WaterSupplyWell: FROM TO DiAMETERlJ SLOTSIZEdd THICKNESS MATERIAL
❑Agricultural ❑ al/Public ft f. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) _9
❑lni tion ❑Wells>100,000GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
\ Non-Water Supply Well: O ft 22 ft Bentonite Hole Plug
Q []Monitoring ❑Recovery fr. fL
\ Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft - ft
❑Geothermal(Closed Loop) ❑Tracer j7
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DEs Vn eo , ess,sovrorx type,gin si�ea.
0 ft. J ti rt. Xccl
4.Date Well(s)Completed: �lJa Well ID# �'� ft' �� ft s
Sa.W Well Location: �G'a ft. / fr.
^'41ft ft. SOJL6 e_
Facility/Ow�Name Facility 1D#(if applicable) / fL yS fL L Y
Physical Ad Ci and Zip
it. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in.degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) r
22 Certifi n: .: '
35?J Gj' `S N 80�,
6.Is(are)the well(s):'l>gPermanent or ❑Temporary Signaeuce of Certi e11 Contractor Date`
By signing this form,I hereby certify that the wells)was(were)constructed m accordance with
7.Is this a repair to an existing well: ❑Yes or 6161 ISA NCAC 02C.0100 or!SA 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 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: C 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_- (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2C3a 100)
Q0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( )Ijwater(evel is above casing,use"+ 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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill 24c-For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
(i e.auger,rotary,cable,direct push etc.) coun environmental health de
ty 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.
Air Permrt Program 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type. Slerllene Amount: CQ
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20Ig