GW1-2022-06942_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRM70N
2464-A it. flit e.1
tt. it.
NC Well Contractor Certification Number
in
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO ft in.DIAMETER - TIr1CKN&SS MATERIAL
// ft.
Company Name ��V �q�
2.Well Construction Permit#:_ FROM I DIAMETER I MUCKMS MATERIAL
List all applicable well construction permits(I e.01C,County,State,Variance,etc.) t1 ft- fL 6 1/8 'n SDR-21 PVC
3.Well Use(check well use): ft. ft �n 2gg
Water Supply Well: FROM TO I DIAMETER SLOTSJU TMCWUM MATERIAL
❑Agricultural ❑ icipal/Public ft. it. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft in
01ndustrial/Commercial ❑Residential Water Supply(shared). - -- - --
❑Irri ation ❑Wells>100,000GPD FROM To MATERIAL EMPLACEMENrMETROD&AMOUNT
Non-Water Supply Well: 0 fL 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery tl. ft
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
OExperimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer ,(
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft TO DFS IPI10 cobr, Hess oi/rock sae err
,D ft
4.Date Well(s)Completed: ../ 11 IDEI 4191 it ft
5a.Well Lo tion: -7-0 fa p ft. S e
Wei c+,� l'� s �� �h►c�;' ft s ft. sc�
Facility/Owner Name F ili IINI(if ap cabl It.
t ft
�50 /�� j 1 V r-'Ely_
Physi Address,City,and ft fL i
�o
County Parcel Identification No.(PIN) 1
�f t�iDt36+t#in
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �.
(if
ong s s!S1yient) � / w22.:C!errdf1n-
35'0,5/ N �O —
6.Is(are)the well(s): 64ermanent or OTemporary Signature of Certifted Well Contractor Date
By signing this form,l hereby cerfiJy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or ISA 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 ofthis record has been provided to the well owner.
repair under 1:21 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 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: � fJ ft)
For multiple wells list all depths if different(example-3@200'and 2(Qa 100) ( Submit this GW-1 within 30 days of well completion per the following-
10.Static water level below top of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
D Information Processing
Ijwarer level is above casing,use"+" ( ) g Unjt�1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6" (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health dep
artment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin¢over 100 000 GPD•Co to D
�Q Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) Method of test-
13b.Disinfection type: Sterllene Amount: n�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018