GW1-2022-06868_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name
FROM TO DESCRWnorq
2464-A d
ft. ft. I •
NC Well Contractor Certification Number - -.--
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DLAMETER THICKNESS MATERLII
ft ft. in.
Company Name
2.Well Construction Permit#: 7 FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) 1 +1 I 'L 6 118'; in SDR-21 PVC.
3.Well Use(check well use): CjIt. DDft d 3 n.
Water Supply Well: FROM I TO I DIAMETER 11 SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑M cipal/Public ft- ft.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared). _- -
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O n• 22 1 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 ❑Stonnwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer "
FROM TO D ON luri hardness,soihock size,eta
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
t
4.Date Well(s)Completed: Well M# fL 6 0 ft.
' �v ft. 2�rft. riL
Sze.W�Lod�.'Wee
ft.
Facility/Owner N e 1 Facility 1D#(if ap licable) it. ft.
_G 7 �� ft n1�C� 1'
Physi Address,City,and ft. ft./nd Zip 7
r�l
County Parcel Identification No.(PIN) i "a•�i-t e�a F•
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
IPJPO;t��r1TICl PCC� � '1 i
(if well fiel on99e la1/long is sufficient) / / ZZ.Certifi
35 n
/./ . << N 0&-t� / v2 �9j W Y 1 �
6.Ls(are)the well(s): ermanent or ❑Temporary Sign e,tifigdlAwl Conhac[or' Dace
By signing this form,I hereby certIfy that the well(s)was(were)constructed to accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill oat 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 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: i
p ft 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths tfdifferent(example-3(200'and 2@100) ( ) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 00 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6" (in,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, MSC,Raleigh,Nd 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: I I Copy DWR,CCPCUA
24d.For Water Wells For Water We1lsProduciniover 100 000 GPD100 000 GPD•Co to D
f Pem1lt Program,1611 MSC,Raleigh',NC 27699-1 111
13a.Yield(gpm) I Method of test:AI r
13b.Disinfection type: Ste rllene Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018