GW1-2022-08948_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Onl
I.Well Contractor Information: '
�.t4ae.�0.u? 3vm S l•P.f' R......d.--' {
Ricky Corriher
Well Contractor Name — — FROM. TO DESCRDrfION
2464-A �c �,=s ult, ft. ft. I
11 iii,Sn�^ss+{`3;1 i t< Pf®ft.
NC Well Contractor Certification Number Jtip (3L aft. El-(
Frank A. Corriher& Sons'Well Drilling, Inc. oM TO DIAMETER THICKNESS MATERIAL
Company Name ,
ft. ft. in.
3�q - -
2..Well Construction Permit#'_ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construcrton permits(i.e.UIC,County,State,Variance,etc) +1 ft' fi 6 1/$ 1° SDR-21 PVC
3.Well Use(check well use): 2fL. fL t in. Q t
Water Supply Well:
❑ CUltllral FROM TO DIAMETER SLOTS IZE CKNESS MATERIAL
❑M cipal/Public R
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) `
fL
❑lndustrial/Commercial ❑Residential Water Supply(shared). - -- -
❑11Ti at'ton ❑Wells>100.000GPD FRO Mc TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: 1 0 fL 22 k- Bentonite Hole Plug
❑Monitoring ❑Recovery -ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft. i
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO 0 MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fc ft.
❑Experimental Technology ❑Subsidence Control ft -ft.
❑Geothermal(Closed Loop) ❑Tracer - k
❑Geothermal(Heatin Coolin Return ❑Other FROM TO DESCRMnON arolor,hardness,soil(Heating(Cooling ) (explain under#21 Remarks) ft. fL sia etc
tT.6 at1.
4.Date Well(s)Completed: Well ID# ft. ft. D Q�
Sa.Well Location: R 4/ ft. a
Facility/Owner Name Faci i ID#(if applicably ft. f.
Phyr' ddress,City,and Zip f4 ) ft•9. -
r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifi n:
35 p .� 80 0- 3/ ' Z/� �� W N � L
14)
6.Is(are)the wll(s): l6fermanent or ❑Temporary signature of Certifi ell Contractor �
Daze
By signing this form I hereby cert fy 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(s)
Construction Standards and that a copy
If this is a repair,fiU our known well construction information and explain the nature oft of this record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
&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-I is needed.1 Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box):You may also attach additional pages if necessary.drilled:
n INSTRUCTIONS
9.Total well depth below land surface: !T 0S (ft.) 24.SUBMITTAL
For multiple wells list ail depths ifd fferent(example-3@200nand 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. Err (in.) 24b.For Infection Wells:Copy to!DWR,Underground Injection Control(Ill
12.Well construction method.
Air Drill Proms,1636 MSC;Raleigh,NC 27699-1636
'
(Le,auger,rotary,cable,direct push,etc.) 24c.For Water Su I and O eu-Loon Geothermal Return Wells:Copy to the
county environmental Iludiul department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Co to D
a © Air Permit Program,l 11 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) Method of test
13b.Disinfection type: Stenlene Amount: C� S
i
Form GW-1 North Carolina Department of Environmental Quality /Q ty-Division of Water Resources { Revised 6-6-2018
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