GW1-2022-06527_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIPTION
2464-A `eft. Q ft. �D
ft. ft.
NC Well Contractor Certification Number
.
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL _
ft. ft,
Company Name in.
v �� ram'
� 5'��I1YAIER�C�1�jT�p {B�_ 'etitltec_ma)i-cT�us
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
SList all applicable well constructionpermils(i.e.U1C,County,State,Variance,etc.) +1 R• ft 6 1/8 in•. SDR-21 PVC.
3.Well Use(check well use): ft. ft. �
41 Water Supply Well: :
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL v❑Agricultural ❑M icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single). ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared), GRO -
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0. ft. 22 Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge ❑Groundwater Remediation n• ft.
(tom ❑Aquifer Storage and Recovery ❑Salini Barrier
v ty FROM TO MATERIAL 1 T
U ❑Aquifer Test ❑Stormwater Drainage fc. ft. EMPLACEMENT METHOD
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 0 a cf„adaiwafighee sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfroc%type, n size etc
D ft. vU ft.
ir" W
4.DaatteWell(s)Completed:�y Well ID# L—i,c7 ft. ft.
591 C6tuion.:
♦ ( �� / S d ft. ;/ y ft. CJ L
Facility/Owner Name Facility 1D#(if appli able) ft. /ft. K3
Physical Address,City,and Zip ft ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v ✓
(ifwell field,one lat/lo g is suflicie )
� / /l 22.Certifi n: f9Yi'3'iAE`iil pfr'R '•eF
35& 7 35 N 80O - LIB -�� W �� p1�;,W,Of3
6.Is(are)the well(s): kferm anent or ❑Temporary Signature of Certifi ell Contractor Date
By signing this form,1 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
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 1121 remarks section or on the back ojthis 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-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: /� (fG)
For multiple wells fist all depths tjdiJjerenr(example-3@200�2@@1100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: C1 (fh) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljwaterlevel is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
.(in) 24b.For infection Wells:Copy to D WR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 Ion 000 GPD•Co to D
(J Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) Method of test: /
13b.Disinfection type- Sterllene Amount: a^C C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018