GW1-2022-10685_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name
ft �
2464-A ft ft
NC Well Contractor Certification Number —
Frank'A. Corriher& Sons Well Drilling; Inc. FROM I TO DIAMETER I THICKNESS I MATERIAL
fL fL in
CotnpanyName �
2.Well Construction Permit#: I XU ! FROM TO I DIAMETER THICKNESs MATERIAL
List all applicable well construction permits CU.UIC,County,State,Variance,etc.) +1 ft �D ft 6 1/g 1D SD R-21 PVC
3.Well Use(check well use): ft
Water Supply Well: FROM TO DIAMETER SLOT 612E THICKNESS MATERIAL
❑Agricultural ❑ cipaMbhc fL ft in
❑Geothermal(Heating(Cooling Supply) esidentiaI Water Supply(single) % ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000GPD FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery 4FROMTO
ft
Injection Well: ft
❑Aquifer Recharge ❑Groundwater-Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer - -
FROM TO DES ON color, eat, D/roek eta
❑Geothermal eating(Cooling Return) ❑Other(explain under#21 Remarks) Q fL 70
fL
4.Date Well(s)Completed:, E-12,
" Well ID# -7 D ft l ft t
52.Well Lora'on: 6 3 ft qoS fL k �e
3 4 I ft. ft.
F[ac�ili �N /� Facility ID#(if applicable it it "e.^'��� '' ; .y yr
Cre Q l ft fL
A
Physi Address,City,and ft M DEC
ess
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one,Wong is sufficient) 22.Ce catio
35 N 800 -39 g '' W
6.Is(are)the well(s): 661manent or ❑Temporary Signature of c6tified 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 o 1 SA NCAC 02C.0100 or ISA 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 wen owner.
repair under#21 remarks section or on the back ofb5is 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.
dulled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �) U ; (ft
Far multiple wells list all depths ifdiffeent(example-3p200'and 2@100* ) Submit this GW-1 within 30 days of well 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 water 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 Program,1636 MSC,Raleigh,NC 27699-1636
I(Le 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
C3 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test.
13b.Disinfection type: Ste rilene Amount: </
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018