GW1-2022-07247_Well Construction - GW1_20220805

WELL UONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Ricky Corr iher -
Well Contractor Nam
TO DESCRD'TION
2464-A ` ft
�NC Well Connector Certification Number �f t z z ai
-
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER Tmi avirss - MATERIAL
!t fL in.
Cotapany Name � 7�/9> �� =11U
2.Well Construction Permit#: THIC MESSList all applicable well construction permits(ce.UIC,County,State,Variance,eta) to SDR-213.Well Use(check well use): '°
FROM TO DIAMETER SLOT SUM TffiCIQIESS MATERLV
Water Supply Well:
❑Agricultural OM -cipal/Public ft ft fIf in.
[]Geothermal(HeatinglCooling Supply) esidential Water Supply(single) ft. ft '`iul
❑Industrial/Commercial ❑Residential Water Supply(shared)
13hrigation ❑Wells>100000GPD FROM I TO MATERIAL I EMPLACEME—MEMOD&AMouNT
Non-Water Supply Well: 0 ft' 122 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEIMAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft
b
❑Experimental Technology ❑Subsidence Control it ft. I'
I, l
❑Geothermal(Closed Loop) []Tracer
FROM I TO --- DES O14[tolorlai sollfrockrym gram. size,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under.#21 Remarks) el it L� ft
4.Date Well(s)Completed: Well 1D# ( ft O ft ?S;C
5a.Well Location: p ft �0 ft O z
e .S'a�r.+� It I G
Facility/Owner Name Faciliryy ID#(if applicable) ft. ft
ft ft
Physical Address,City,and Zip R ft
Ja P90
Canty Parcel Identification No.(PIN) '� y
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field,one lat/long is sufficient) �! 2022
1 22.C ratio 6 .
35 _3 ! " N 800 7�— , Into - lion Pry,.
6.Is(are)the well(s): ermanent or ❑Temporary Sigoatme of ed We Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and drat a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (C� ft)
For multiple wells lfstall depths iJ di8erent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (- O ft-) 242. For All Wells: Original form to Division of Water Resources (DWR),
If ivater level is above casing,use"+ Information Processing Unit,161'MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" On-) 24b.For Injection Wells:Copy td DWR,Underground Injection Control(IUC)
12.Well construction method:Air Drill
Program,1636 MSC,Raleigh,NC 27699-1636
�• '
24c.For Water Supply and Opea-Loop Geothermal Return Wells:Copy to the
ush,etc.) county environmental
(i e.auger,rotary,cable,direct p health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producaia over 100.000 GPD•Copy to DWR,CCPCUA
m) st;Ai r
13a.Yield(gp Method of te Permit Program+1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Ste ri I e n e Amount: CC
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 6 6-2018