GW1-2022-08416_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher - -
FROM TO DESCRIPTION
WellConlractorNatne fL ft
2464-A AY5-r,. 5Z97—)fL -9
NC Well Contractor Certification Number ---
Frank A. Corriher& Sons Well Drilling, Inc. FRO M To DIAMETER TTTlclavFss MATERIAL
fL � fL ;n.
Company Name
2.Well Construction Permit#: 7,5-?-
�3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) +1 fLZ-F—
fL 6 1/8 in S lDR-21 PVC
3.Well Use(check well Ilse): �fL 6 fti ,�1O (is— Q
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M 'cipal/Pubhc ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft fL in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
❑Irri 'On ❑Wells>100,000 GPD °M TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
Non-Water Supply Well: O fL 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery fL ft
Injection Well:
ft fL
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Battier FROM TO MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage M ft
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hatdueaa,seiVmcktype,gmin size,etc.)
fL 54, ft
4-Date Well(s)Completed, y Well ID# ^) ft 0 fL
Sa.Well Location: t. :3& it yC
rL fL
Facility/ Name Facility #(if a is le) ft fL
ft 7
Pb;sical Address,City,and Zip ft fL
��
J =a rt�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laVlong is sufficient) �ee J r 22rCe7tio
35C} ' "N 80O -- �S W G" �� -
6.1s(are)the well(s): ermanent or ❑Temporary Signanue of ed Well Contractor Date
By signing this form.1 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 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#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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
wed' n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ll� (ft.)
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) Submit this GW-1 within 30 days of well completion per the following:
�� 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft) Information Processin Unit, MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" g �•
11.Borehole diameter:6" (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger,rotary,cable,direct push,etc.).Well construction method:AI r Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
`� Air Permit Program.1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) J � Method of test:
13b.Disinfectiontype: Sterilene Amount:
--r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018