GW1-2022-06871_Well Construction - GW1_20220719

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name ���• ft•
2464-A
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
/ f-- ft. in.
Company Name FJ� - - — -
2.Well Construction Permit#.•���J��j FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.Ufa County,State,Variance,etc.) +1 fL ft- 6 1/8 in- SDR-21 1PVC
3.Well Use(check well ruse): fL � ft -in. tr?'_ q
Water Supply Well: FROM I To DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) hfResidential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared). r----
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery it. ft.
Injection Well:
uifer Recharge ft. ft
❑A q arge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft j
❑Experimental Technology ❑Subsidence Control ft. ft.
�. ❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal FROM TO DES ON cobr, ness i/eoek ' size,etc
(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
`� � ft. L.J fL
4.Date Well(s)Completed: �J 1 Well ID# y!0 ft- L ft
Ci 5a.Well Location: 6 a ft. ft. S v I
V `"T�h ra 17�z°lyr��Sa�► t• IY.S f ice
Facility/Owner Naame Facility ID#(if applica VOW3
ft. h aI f a
ft
Ph5 s'J Address,City,and Zip ft. fL
County Parcel Identification No.(PIN) t ra-.t '4!-
Sb.Latitude and longitude indegrees/m rn inutes/seads or decimal degrees: 1 � f�''��•":��',(? 1 P'I a-.�?.:•[I I`I j
(ifwell field,one latllong is sufficient) / 22.Certifi n {
35 Oc7 '-S-/'� N fflo 3�— /0
'zq�� -I--,
6.Is(are)the well(s): e neat or OTemporary Signature of Certifi ell Connac[or; Date
By 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 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 921 remarks section or on the back of this 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 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells (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:
for multiple wells Iist aB depths ifd fferent(example-3@200'and 2@100) ( ) Submit this GW4 within 30 days of well completion per the following:
10.Static water level below top of easing:- 242. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,use"=" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 61
1
(in.) 24b.For Iniection Wells:C0py;t0 DWR Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill I
(' g tary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
r e.auger,ro county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells pro ducin¢over 100,000 GPD•Co to D
[� Permit Program, MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) / ® Method of test:AI r .
i
13b.Disinfection type: Sterilene Amount u S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resour Ies Revised 6-6-2ois