GW1-2022-06867_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name FROM
po 0 ft ft try
2464-A ft ft
NC Well Contractor Certification Number -- —
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DLIMETER IMCKNESS MATERIAL
ft it in.
Company Name -/��"
----
9 �2.Well Construction Permit#:2 FROM TO DL►.ME'rER I THIcxivEss MATERIAL
List all applicable well construction permits(z.e.UIC,County,State,variance,etc.) +1 ft Y7 ft 6 1/8 I in- SDR-21 PVC
3.Well Use(check well use): %7
Water Supply Well: FROM TO DLIMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ;2rid�etial
/Publie ft. ft iu
❑Geothermal(leating/Cooling Supply) Water Supply(single) ft ft in.
Olnduustrial/Commercial ❑Residential Water Supply(shared)
❑Irri lion []Wells>100,000 GPD FROM TO MATERLII EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Well: O fL 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery fL ft.
Injection Well: ft ft.
❑Aquiifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCR>PTION ro soiRoetc u�I
D it J�?h ft 'ei i
4.Date Well(s)Completed: Well # Q ft. it
ID Q
LC �-
S�a.,W �'l ft. 2aS ft
Well /�
VV �l 1CA,172 / /�U_r �Cif
ft it .
Facility/Ow,per Name Facility ID#(if appli�l '�o� ft. ft.
fL fL
Ph - 1 Address,City,and Zip it it;:
Canty Parcel Identification No.1,T>M
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) " 2aLn:
Nsonf-3 9- O W � ' 76.ls(are)the well(s): ermanent or ❑Temporary S4W. on for Date r
ey 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 ;roz 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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#21 remarks section or on the back of thisform. 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 1 GW-1 is needed Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
wed' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) I'
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original folrm to Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I i
11.Borehole diameter 6° (in,) 24b.For Injection Wells:Copy to DWI;,Underground Injection Control WC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r 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 Wm) Method of test:
Air Permit Program,1611 MSC,Raleigh,'NC 27699-1611 I I
13b.Disinfection type. SterileneAmount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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