GW1-2022-06869_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FRO TO DFSCREMON
Well Contractor Name 1„ t,
2464-A �Y
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. EOM To DIAMETER THICKNESS MATERIAL
f, ft. in.
Company Name -
2.Well Construction Permit.34. / FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State,variance,eta) +1 ft. eZff 6 1/8 , in. SDR-21 PVC
3.Well Use(check well use): •o°L / fr 1 i' C. v
Water Supply Well: FROM To DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ cipab?ublic fL ft. iri.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) %
❑Industrial/Commercial ❑Residential Water Supply(shared). gWMMgnM,
ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METMOD&AMOUNT
Non-Water Supply Well: 0 f° 22 Bentonite Hole Plug
❑Monitoring ❑Recovery ft. fL
Injection Well: fr,
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENr METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer TtWON
❑Geothermal FROM TO DESCREMON color,hardness.soi/rock dw,ete.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. ' ft. 1^0 4J K)
4.Date Well(s)Completed: ' Well ID# ft. �/ fr
5a.Well Location:/' 5KI
Facility/Owner Name Facility (if ft- fL
/0-7r R(q11,4,e-1 rn
fL ft-
Physic Address,City,and Zip ft. fL Pd 1 S
� nT �� _. .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wc�llll field,
eld,one ladlong is sufficient) �p C,- 22.:=�:
`3`{l 7!��� N 8Q�- �� W IZd'/_ ���e�—Oqa
6.Is(are)the well(s): el Venent or ❑Temporary Signature of Certi well Contractor Date
By signing this form,I hereby certify that the we//(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
Ifthis is a repair,fill out(mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 021 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobc/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: ��^/- ) Submit this GW-1 within 30 da:s of well completion r the following:for multiple wells list all depths ifdifferent(example-3(a 200'and 2(Qa 100) y P per g:
30 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (f� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"�" � ,
11.Borehole diameter: 61' (in) 24b.For Iniection Wells:Copy,to,DWR,Underground Injection Control(TUC)
Program, MSC,Raleigh,NC 27699-1636
12.Well construction method:
Air Drill(i.e.auger,rotary,cable direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the cotmty where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: r
Air Pet Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type:Sterllene Amount: ev
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 6-6-2018