GW1-2022-10684_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher --- - -
Well Contractor Name FROM TO DESCRIPTION
2464-A �t 3 / t '
NC Well Contractor Certification Number - -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DLAMETER THICKNESS MATERIAL
gr`Co lY¢LLpNa;�
OW
$on Permit#: U '73 FROM ' TO - DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) +1 ft (i ft 6 1/8 'n SD R-21 PVC
3.Well Use(check well use): ft. r! Cz 0
Wa r Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural � srmcipal/Public ft it ib
❑Geothermal(Heating(Cooling Supply) %.,midential Water Supply(single) ' % it in.
. ❑Industrial/Commercial ❑Residential Water Supply(shared)
[]Irrigation ❑Wells>100,000GPD FROM To MATERIAL I EMPLACEMENT MEmOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Be6tonite Hole Plug
(� ❑Monitoring ❑Recovery ft ft
Injection Well: - it ft
\\ OAquifer Recharge ❑Groundwater.Remediation
❑Aquifer Storage and Recovery ❑Salinity Barber FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES ON for, ess,sonlrock type,gimin size,etc
ft
ft
� mod'
4.Date Well Well ID#s)Completed: -7 , t ft ft
5a.Well Location: L �-3 ft C J�
Facility/Ow ap Facility/Owner Name Facility ID#(if licable) ft ft
/ g VJr G� l�,�f �� �e�ie�a'ed it it Dr C J 20ZZ
Physi ddress,City,and Zip ft. it
a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laOong is sufficient) /,� `� /./ 22.C ratio
350a 1 �N $oo "7�-Z W
1 , - zg
6.Is(are)the well(s): b ermanent or ❑Temporary Signature ofC6tffled Well Contractor Date
By signing thisform,I hereby certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or It o 1 SA NCAC 02C.0100 or 1 SA 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 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.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdifjerent(example-3 a@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: �i_ (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: 6" (in-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drill
(L Program,1636 MSC,Raleigh,!NC 27699-1636
.Well construction method: 24c.For Water Supply and Open-Loop 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 producing over 100,000 GPD•Copy to DWR,CCPCUA
/� Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 10 Method of test: C
13b.Disinfection type: Ste ri I e n e Amount: oe?
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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