GW1-2022-06526_Well Construction - GW1_20220601

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name
FROM TO DESCRIPTION
ft. ft
2464-A d
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
O ■ ft. ft. in.
f\ 1J Company Name /1 (/�/� � __. -_r
v 2.Well Construction Permit#• OV FROM I TO DrAMETER TfnC1QQESS I MATERIAL
List all applicable well constructionpermils(I.e.UIC,County,State,Variance,etc.) t1 ft d-1 fL 6 1/g I"• SDR-21 PVC.
3.Well Use(check well use): v2 ft p2 3 fL 7 2
Water Supply Well:
\� FROM I TO I DKAMErER SLOTSIZE 1 THICKNESS MATERIAL
7��11 ❑Agricultural ❑ icipaUPublic fL ft. in.
❑Geothermal(Heating/Cooling Supply) V esidential Water Supply(single) fr ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared).
(� 01rri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 22 ft- Benl:onite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
\� ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM a TO MATERIAL EMP1acEMFxrMETHOD
N ❑Aquifer Test ❑StormwaterDrainage ft. ft
❑Experimental Technology ❑Subsidence Control fa ft.
(� ❑Geothermal(Closed Loop) ❑Tracer
�,-�`` ❑Geothermal FROM TO DESCRIPTION color•hardness,so rock am etc
(Heating/Cooling Return) ❑ er(explain under#21 Remarks) D ft 1 rl ft w
vim— �
4.Date Well(s)Completed:�-nf— Well ID# L-- ft. a3 fL
5a.Well cation: OZ3 ft• ft. r4 le-
Facility/Owner Name iliry Ill#(if applicable ft. �'�pp
a 1�!tee
ft. ft.
�i Physical Ad ss,City,and Zip fL
fill
V County Parcel Identification No.(PIN) LFtt
- 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laOong is s ent) 1 / 22.Certifi n
35l391a� N 800 - 4/7 0� W J�
6.Is(are)the well(s): 10e'rmanent or ❑Temporary Signature of Certifi e11 Contractor Date
By signing rhis 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 ISA 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 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: (ft)
For multiple wells list all depths ifdifferent(example- a�00,and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (3 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwarer level is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 60 (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air D rill
(' g rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD•Co to D
h Permit Pro ram,1611 MSC,Ralet h NC 27699-161 I Copy CCPCUA
13a.Yield(gpm) .� Method of test:Air g g ,
13b.Disinfection type: Stenlene Amount: 91
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018