GW1-2022-10632_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD(GW-1) For lnternal Use OnlT
1.Well Contractor Information:
Ricky Corriher
FROM�� TODESCRn'TION
Well ConttactorName 7J d , l rZ C
2464-A f
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. °M TO TWERNM 1�►TERUL
ft. ft.
Na� � ��
2.Well Construction Permit#: FROM TO DIAMETER TffiCENES5 MATERIAL
List all applicable will consdvetion permits(t e.WC,Couuy State,variance etc) +1 —1 ft. 6 1/8 in. SDR-21 PVC
3.Well Use(check well use): 7 J 73 S 1- e j {/
Water Supply Wen: FROM TO DIAMETER SI OT SrLE MUCENM MATERIAL
pAgriculaual ❑ ipaUPublic it ft in
❑Geothermal(Heating/Cooling Supply) idential Water Supply(ogle) fL ft in.
❑Industrial/Commerciai ❑Residential Water Supply(shared)
❑lni 'aII "�;` ?I, Lf1 100,000 GPD FROM TO MATERIAL EMPLACEMENT mrruw&AMoDNT
Non-Water Supply w :�a-..�� b 0 n- 22 fL_ Bentonite Hole Plug
OMonitoring very ft. ft
Injection well: fL ft-
❑AquiferRecl>atge Pr^ 9tWd> aterRemediation
oAquifer Storage and 10ECOVClyJ+f,`Qil��salmity Barrier FROM To MAr81anL EMPLAc6b>QrSrrMETaon
0Aquifer Test ❑Stormwater Drainage tr• ft.
DExpeaimental Technology ❑Subsidence Control tr- fL
J 13Geothetmal(Closed loop) ❑Tracer
FROM TO D ON br runtiness soNeoelt etc
pGeothetmal Cooling Return) ❑Other(explain under#21 Remarks) ft ,w&
I>-74
4.Date Well(s)Completed: Well ID# S�� SIN'
5a Lora .S� rJ L tL
�PQ d0 i�1 �°fC 7.3 2 r
Fae ' Owner amo Facility IIht(if app' 1 ft ft
ft. fL
Zip ft. fL
732 yX o?041
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degreeslminateslseconds or decimal degrees:
(if well field,one latllong is sufficient) p 22 C ratio
35 �� N 800 l d w -
6,
of ed
6.Is(are)the wen(s): ermanent or ❑Temporary sign - Well Contractor Date
By signing this form.I hereby coot fv d-the—11(s)was(were)constructed m accordance wide
7.Is this a repair to an existing well;- ❑Yes or o 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction S7andd rds and than a copy,
Ifdds is a repair ftAout known well construction information and explain the nature ofthe of dds record has been provided to the well owner.
repair raider#21 remade section or on the back of dds form. 23,Site diagram Or additional well details:
8.For GeoprobeIDPT 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 Rernar3cs Box).You may also attach additional pages if necessary.
drilled' ) �� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y VL) GW Submit this -i within 30 days of well For multiple wells list all depdu if differeru(eaampk-3Q200'and 2Qa 100) ys completion per the following:
10.Static water level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If ureter level is above casing use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (m) 24b.For Injection Wells:Copy to DWR,Underground Injection Control('IUC)
Program,1636 MSC,Raleigh NC 27699-1636
12.Wen construction method:Ai r D ri I I
(Le,
Zac.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
augr�rotary,cable'direct push,Fro) county environmental health department of the county where installed
FOR WATER SUPPLY VvT LLS ONLY: 1
24d.For Water Wells producing over 100,000 GPD•Copy to DWR.CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type. Sterilene Amount_
Form ow-1 North Carolina Department of Environmental Quality-Division of Water Res'ounces Revised 6-6-2018