GW1-2022-04841_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher _
Well Contractor Name EOM TO DESCRI]MON
2464-A
ft, ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIgI
ft
Company Name ft. in.
-� � ..r� � - -- - - --
2.Well Construction Permit#: q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UlC,County,Stale,Variance,etc.) t1 SDR-21 PVC
�e 3.Well Use(check well use): ft G ft t C,in o
\ Water Supply Well: J c
❑A Cultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
! cipaUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) tesidential Water Supply(single) in
1 ❑Industrial/Commercial ❑Residential Water Supply(shared) - ----
~ ❑lrri ation ❑Wells>100,000GPD FROMr I TO MATERIAL EMPLACEMENrMETHOD&AMOUNT
Non-Water Supply Well: 0 'L 22 IL Bentonite Hole plug
❑Monitoring ❑Recovery fL ft.
Injection Well:
Oft• ft❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL
EMPLACEMENT METHOD
❑Aquifer Test ❑StArmwater Drainage it. ft.
❑Experimental Technology ❑Subsidence Control ft. ft•
❑Geothermal(Closed Loop) ❑Tracer FROM
- -
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fc TO D ON color,h r, Frockt q - Simill,etc
4.Date Well(s) _a9 3
Completed: Well DJ# ft. ft. 5�
5a ell Location: �j Zft• } ft. L , -
Fac' ame 10 Facility lD#(if ap lira Qf,,. © 2022
ft ft.
4W/'Q
I-29
AQ GCJ g ft
Physical Address,City,and Zip V R. ft, r& 9
�rw
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
c35well
V field,one la�t(long;s sufficient) 22.Certiti n•
N soe 7
W
6.Is(are)the well(s): bf ermanent or ❑Temporaco newlith
ry Signature of Certifi ell Contractor Date
BY signing this form,l hereby certify that the wells was
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C'.0.20o Well Construction Sla(were)construcndartds and Char a copy
Ythis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner. - -
repair under Ul remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For Geoprobell 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box),You may also attach additional pages if necessary.
drilled:
S 24•SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (�)
For multiple wells list all depths ifdtfferenr(example-s(a3200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:_ O (�) 24a,, For All Wells: Original form to Division of Water Resources (DWR)
Ifwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in,) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
'
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Sunply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Droducine ovIII:? kner 100 000 GPD Co to D
PY WR,CCPCUA
13a.Yield(gpm) Method of test..AI r Permit Program,1611 MSC,Raleigh i NC 27699-1611
13b.Disinfection type: `Merl lens Amoul C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018