GW1-2022-06877_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Ricky Corriher -
OM I TO I DESCRIPITON
Well Contractor Name
2464-A
NC Well Contractor Certification Number
Frank A. Corriher & Sons Well Drilling, Inc. FROM To DIAMETER THICKNESS
ft. ft.
—� Company Name
��c��
FROM TO DIAMETER TIIICI4VESS MATERIAL
2.Well Construction Permit#: ,
List all applicable well construction permits ri.e.UIC,County,State.Variance,etc.) ft. fL 6 1/8 '"' SDR-21 PVC.
ft ft. ; a f�
3.Well Use(check well use): v
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICIIN68S MATERIAL
❑Agricultural ❑ lcipal/Public ft. ft. in•
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft.
® iu•
-
❑IndustriaUCommercial ❑Residential Water Supply(shared) - -
❑Irri ation ❑Wells>100,000-GPD FROM TO I MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 22 ft Bentonite JHole Plug
t 1 ❑Monitoring ❑Recovery ft. ft•
�vJ Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation - -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer _ f ' .
FROM TO DFS ON color hardness,soi/rock tYPe,ZrRin sia.etu
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /�
4.Date Well(s)Completed: t ell ID# ` ft lZ� ft S Q
5a.Well Location:
ILI C _/'a
Facility/�O jwner a Facility ID#(if appli a .Ti-
�/✓ o f< f 022.
Physic Address]City,and ip
J Crie ! 1. MOj
County Parcel Identification No.(PIN) t yC
NGUNH
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient 22.Certifi lion:
33 � '�1N 80(J - ' w
i tu
6.Is(are)the weU 7'e(s): ® rmanent or ❑Tempora�o/
Sgnare of Ce i ell Contractor Date
By signing this fors.,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or 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 r,'emarks 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 of wells (add'See Ovet'in Remarks Box). ,You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '"J (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2()a 100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
Err 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well corstruction method:AI r D rI I I 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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(gpm) Method of test:
Air Permit Program,
1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection type: Sterllene Amount: C7l
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesl Revised 6-6-2019