GW1-2022-10246_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher -
Well Contractor Name
FROM TO I DESCRIPTION
2464-A //Vt /,2
NC Well Contractor Certification Number --
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER TffiS MATERIAL
[L ft is
Company Name Iq _
2.Well Construction Permit#: {� IeGJ Id/ FROM To D1nMETER IMCK ESS MATERIAL,
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) +1 ft 3.2 ft 6 1/$ ,n. SDR-21 PVC
3.Well Use(check well use): tMom
3 y 6 ;��rn f � 4
Water Supply Well: TO DIAMETER SLOT SIZE TMCKNESS MATERIAL
OAgriculttual O/.idi.
al/Public ft, in.
❑Geothermal(Heating(Cooling Supply) tial Water Supply(single) ft in.
❑Iadustlial/Commercial OResidential Water Supply(shared) t
❑hri 'on O Wells>100,000 GPD TO MATERLAL EMPLACEMENT ME-raOD&AMOUNT
Non-Water Supply Well: O it 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft.
Injection Well:
tt
❑Aquifer Recharge ❑ nGroundwater Remediatio
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENTM M01)
OAquifer Test O Stormwater Drainage ft- it
OExperimental Technology ❑Subsidence Contiol ft. ft
d ❑Geothermal(Closed Loop) ❑Tracer
❑V Geothermal(Heating/Cooling Return) ❑Other(e FROM TO DESOcolorem soilfrak ek.
lain tinder#21 Remarks) D fL �z &
1 1—
%d 4.Date Well(s)Completed: - o dQyell ID# .20 ft 3 tt S' L
5a.Well Location:
ft. 6 rt r�
�i'e e d fl iL �ft. .
Facility/Owner Nate Facility ID#(if applicable) ft. it
roc Physical � ft o� P Address.City.and Zip b um
—oZ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.2y7tio
350, 3 3 ' 3�1 N 80Q ,0- oq 111 W zo
6.Is(are)the well(s): ertnanent or ❑Temporary Signature of CYrtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 01C.0100 or]SA NCAC 02C.0100 WeU 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) Submit this s co r For multiple wells list aallif depths different(example-3@200'and 2@100 GW-1 within 30 day of well completion per the folio
� mp wing:
24a. 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 Basin&use"+"
11.Borehole diameter: 6° (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction AI r Drill 24c.For Water Supply and open-Loop Geothermal Return Wells Copy to the
(ie.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produciu2 over 100,000 GPD:Copy to DWR,CCPCUA
Air Permit Program,I bl I MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test. /!
13b.Disinfection type: Sterilene Amount: C�
i
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018
i