GW1-2022-09639_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher 4 � 0
Well Contractor Na FROM TO DESCRIPTION
Nam
© ft. ft
2464-A Orz
ft. ft.
NC Well Contractor Certification Number - r —
'.SJT�TBR' S or'am"�1htssed. OP >�"'"'Lca`ti
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
ft ft I in.
Company Name �C�J 63NNE1Y�"IDXCQIif[aOB eoxhemaYlc osedo.
2.Well Construction Permit#: , ✓ FROM TO DIAMETER THICKNESS MATERIAL aQ
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft ® ft 6 1/$ rn SDR-21 PVC /
3.Well Use(check well use): �Y! ft -j ft is 1'Gl L
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
DAgricultural ❑/eidntial
1 al/Public tt it is
P
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft %
❑Industrial/Commercial ❑Residential Water Supply(shared) GRO;Ii
71niection
on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
^ ter Supply Well: o rt 22 rt Bentonite Hole Plug
\ ring ❑Recovery ft ft
Well: ft ft
r Recharge El Groundwater Remediation
14SA2IDIG1�t�I'�AG>�'iL"s"�Lcatile ,.. -.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
f ❑Aquifer Test ❑Stormwater Drainage ft. TO
❑Experimental Technology ❑Subsidence Control it fL
►�J 11 ❑Geothermal(Closed Loop) ❑Tracer O R Tc � antic DESCRIPTION
(i fwecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hard soi0rnek e a size etc.)
1 J/ ft t f
4.Date Well(s)Completed: —+'` ell ID# ft ft r
5a.Well Location: (a-3 tuft s
ft M
Facility/Owner Name F cility ID#(if applicab rt tt
J �+ `� �002 7
Physical Ad ess,City,and Zip f+l —fl1mcffflavon Prc-.3Ggft UM
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
`j (ifwell field,one lat/long is sufficient) 22.Ce catio
�! 35 d� $�� l! _N 800 �y3 `3y W /
�v 7�
6.Is(are)the well(s): ermanent or ❑TemporaVo
Signature of a fled Well Contractor Date
By signing this form,Iherebv certify 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 ofthis record has been provided to the well owner.
YJ 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 (add See Over'in Remarks Box).You may also attach additional pages if necessary.
4drilled: /� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �Q� (ft.) Submit this GW-1 within 30 days of well completion per the following:
cz' For multiple wells list all depths if different(example-3©200'and 2(a,100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1 M-) Information Processing Unit,161j7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
6" 24b.For Injection Wells: Copy.to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill
24c.For Water Supply and Open-Lobe Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county'where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water,Wells producin¢over 100,000 GPD:Copy to DWR,CCPCUA
Air Permit Program,161;1 MSC,Raleigh,NC,27699-1611
13a.Yield Win) Method of test:
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Wafer Resources Revised 6-6-2018