GW1-2022-07144_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher —J
Well Contractor Name 1 - FROM TO DESCRH'rKON
2464-A ft. ft. 2-I 11
NC Well Contractor Certification Number "" t
3
t .F,1C51L�IC o�;m tL is :K37B 13 - Ift e
Frank A. Corriher& Sons Well Drilling, Inc. ; FRDM TO DIAMETER THICKNESS MATERIAL
Company Name i ft. ft. j in.
TD:L
C 2.Well Construction Permit#: 3/ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructlonpermits(i.e.U1C,County,State,Variance•etc.) +1 ft. ft. 6 1/8 '" SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: dd
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ( ) _ _ ..
Supply Well: O
esi ential Water Supplyshared
❑h anon ❑WME
ells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water rt. 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery -.� ft• ft.
Injection
❑Aquifer Recharge ❑ r&TE �e ti ft. ft.
� water Remediation
2(1'�� €SALVDfGIf3P G�t1 a""licatile T ___
❑Aquifer Storage and Recovery ❑Salin' rr AO FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Test
q ❑Stormwater Drainage ft. ft.
-`` ❑Experimental Technology irtS�n '"UIS tt. ft,
❑Geothermal(Closed Loop) ❑Tracer pt*�fN � o-lbIL clesc>amonafshee - —
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DE Sc ION oioghardness,soi/ruck size etc.
O ft. ft.
✓� � f`
4.Date Well(s)Completed�� Well ID# f 8 It. L n g•
5a ell Location:
I I 7d ft.
Facility/Owner Name Facility 1D#(if ap licable h• ft.
6�� D��.es f� :1���11.7 ft. ft.
Physical Addre ,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wel©eld,one lat/long�sufficient) � 22.Certifi t qi �
35 800
0
N J � /�® P W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certifi ell Contractor Date
By signing this form,1 hereby certify that the wells was 7.Is this a repair to an existing well: ❑Yes orwith
o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stantdardsd inaccordance and that a copy
lfthis 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#21 remarks section or on the hack 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
1IO 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ `� _(ft.)
Far multiple wells list all depths if different(example-3@200'annnd 2@100) Submit this GW-1 within 30 days of well completion per the following:
ot-
10.Static water level below top of casing: S (ft_) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ljwater level is above casing,use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: sn (in.) 246.For Infection Wells:Copy to DWR Underground Injection Control(TUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: I
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open=I lop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: i
24d.For Water Wells nroducin1 over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: [AyI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-1 i
North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i