GW1-2022-08960_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD_ GW-1 For Intemal Use Only: j
1.Well Contractor Information: � � 3�
Ricky Corriher SEP t. 2n22 -
WellContractorName FROM TO DESCRIPTION
2464-A In;;;r :en �r.�c :r: Unil 37 oft 3%Ott lod t/
J��IOi6OG ft ft
NC Well Contractor Certification Number MUM —
Frank A. Corriher& Sons Well Drilling, Inc.
FROM TO DIAMETER TffiCKNESS MATERIAL
ft ft I in
Company Name �n/,Q Q
2.Well Construction Permit#: +7 V � 0 � FROM I TO DIAMETEn TBIcxivEss MnTERlnI
Litt all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) t1 ft ,? fk 1D SDR-21 PVC
3.Well Use(check well use): 5-2—ft- d tt �' � in. f�
Water Supply Well: FROM TO DIAMETER SLOTSIIE THICIINFss MATERIAL
❑Agricultural ❑M 'cipal/Public tt ft. in.
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) ft ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentofiite Hole Plug
QMonitoring ❑Recovery ft. ft
Injection-Well:- _
it ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed hoop) ❑Tracer
❑Geothermal(Heating/Cooling Retam) ❑Other(explain under#21 Remarks) FROM TO DES ON color hardness,wnlroek etc
© ft it
4.Date Well(s)Completed: Well ID# ft ft
5a.Well Location: > 'fL ft S ��
40L '7 L Wit e-
��,
Facility/OwverName Facility ID#(if applicable) it ft 1
fl UL5/1,6, Rd 6o�,��'vl-110 ft
Physical Address,City,and Zip % it
zf
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.Certification:
f
6.1s(are)the well(s): ermaneut or ❑Tempor;OX
Signature of led Well Contractor Date
By signing thisform,I hereby cemfv 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 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 ofthis 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 (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells Cut all depths ifdifferent(example-3©200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
O24a. For All Wells: Original)form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC;Raleigh,NC,27699-1636
12.Well construction method:
Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the-,
(Le.auger,rotary,cable,direct push,etc.) county envu'Unmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodacm' 'over 100,000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield Wm) 100 Method of test:
13b.Disinfection type:Sterilene Amount
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018