GW1-2022-06488_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW-1) For lntemal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A S s fL
NC Well Contractor Certification Number
!d0 ft.
Frank A. Corriher& Sons Well Drilling, Inc. To D,AMETER THICKNESS MATERIAL
ft, fL in.
Company Name �� 40un
/�2.Well Construction Permit##• '( FROM TO DIAMETERKNESSMATERIAL
List all applicable well consirucdonpermtts(i.e.U1Ctate, Variance,etc.) +1 fL ft 6 1/8 '" SDR-21 PVC
3.Well Use(check well use): iz ft.
Water Supply Well:
FROM TO DIAMETER - SLOTsP6E THICKNESS MATERIAL
OAgricul[ural Zidential
ipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft iu.
Olndusttial/Commercial ❑Residential Water Supply(shared).
Olrri ation ❑Wells>100,000GPD FROM To MATERIAL EMPLACE B AMOUNT
CEMEIYI ME7AOD
Non-Water Supply Well: ft
0 22 entonite Hole Plug
❑Monitoring ❑Recov
\ erY
71njectionWell: ❑Groundwater Remediationftnd Recovery OSalinity BarrierM TOMAM OStormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control ft. tt.
OGeothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Retum) ❑Other FROM fL TO DESCRIPTION color,hardness,soi/roek �,
` (explain under#21 Remarks)
4.Date Wells)Comple ell ID# 215--L
\� 5a.Well Location:
4z°,..4�e j((gJD
Facility/Owner ame r r cility ID#(if ap b fL ft.
9,0S��S'�r pile/ �F���� Ii 0��1�>� fL
Ph"*al Address,City,and Zip fL tL
criven
'V3M770 45
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I SING Ili
(ifviell field,one young is s� ! cient) 22.Certif Iwo'
35 ( 8 i i 1
6.Is(are)the well(s): ermanent or ❑Temporary Signature ofCertifi 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
/f 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 911 remarks section or on the back of this form.
23.Site diagram or additional well details:
1i.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consmiction 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: ✓
9.Total well depth below land surface: (ft.) 24.SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifd fferent(example-3@200•and 2Qa 100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: © (fL) 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
1L Borehole diameter. 6" (in,) 24b.For Infection Wells:Copy to'DWR Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger,rotary,cable,direct push,eta) 24c.For Water Supply and Ocen-Loop Geothermal Return Wells Copy to the
county environmental health deparunent of the county where installed
FOR WATER SUPPLY WELLS ONLY:
Q 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test-Air Permit Prograrn.1611 MSC,Ra eigh,NC 27699-1611
13b.Disinfection type: Stenlene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018