GW1-2022-06034_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A 6-5--
/ ft. Pit.
l®
q all
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER I THICKNESS1 MATERIAL
ft. ft, in.
Company Name
�J �JQ _ kCfB eo' ertms¢iosed -
2.Well Construction Permit#: / / FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) +1 ft. ft. 6 1/8 in. SDR-21 PVC
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑eelidential
ipal/Public ft. ft. in.
e� ❑Geothermal(Heating/Cooling Supply) Water Supply(single) tt. ft. in.
�.1 ❑Industria.K.mmercial ❑Residential Water Supply(shared) 9XgGR0
\�\ ❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
(� Non-Water Supply Well: 0 ft' 22 ft- Bentonite Hole Plug
\� ❑Monitoring ❑Recovery ft. ft,
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer -ObR1 [Y o ee -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRUTION color,hardness,soihuck type,grain size,etc
It*
v ft. f
4.Date Well(s)Completed:c 7 a�~�Well ID# C� ft. ft. t„d �'J//
5a.Well Location: ft.
'5ct.rn U a/ Cowzr - ft. ft. _ _ �
Facility/Owner Name J'7 Facility 1D#(if appheabi) )� ft. ft. y V(f f ,�. 't+, `k.t_1
\D'��,vlt/r� tt. ft. 4 `
Physical Address,City,and Zip ft ft. JUIX
go I�/ot /I - -
fJr,
County parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi r�
35 i� N 80? W
6.Is(are)the Well(S): ermanent or ❑Tempora; o/
Signature of Certi6 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 15A NCAC 02C.0100 or 15A NC9C 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 I GW-I 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: /-f (ft.) Submit this GW-1 within 30 days of well completion per the following:(•'or multiple wells list all depths ifdidrent(example-3@200'and 2Qa 100) y P P g:
rn 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
O'water level is above casing,use".
11.Borehole diameter•' 6" (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 Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push etc.) county environmental health department 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 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type.
Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018