_Well Construction - GW1_20230315 (28)

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: '
Ricky Corriher - -- -
WellConttactorNar a FROM TO DESCRIPTION
2464-A C fL S.ort L
ft. ,, It.
NC Well Contractor Certification Number -- -
Frank A. Corriher & Sons Well Drilling, Inc. EOM It. TO DIAMETER Tt°°ICIESS MATERIAL
it in.
Company Name oe
2.Well Construction Permit#: 3 903 / © FROM TO DIAMETER TMCKNESS I MATERIAL,
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) + ft 6 1/g 1° SD R-21 PVC
3.Well Use(check well use): L fit Y4
Water Supply Well:
FROM TO DIAMETER SLOT SIZE I TIUC)CMS I MATERIAL
❑Agricultural ❑ cipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) GXO
❑Iai ation ❑Wells>100,000GPD FROM I TO MATERIAL EMPLACEMENTMMOD&AMOUNT
IN ter Supply Well: O ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery it it
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage aad Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT mgmoD
�. ❑Aquifer Test. ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control it ft
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIP'I'I N color,hardness,soWrock qVe, tc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) 1
t7 ft C7 ft,
4.Date Well(s)Com/pleted: 1 tl� Well ID# 3(� ft qb ft S �
5 llzbal
"'' �' C t'G�✓t S ,] p it l�p ft ILCQi' s�C?/t
ft it I^
Facility/Owner Name p Facility ID#(if applicable)
ft ft
d lg?-,5,-9�nr" �J./" ft ft MAN ? C 1
—
Physt Address,City,and Zip ft M
06Pq
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce cati0
3503b1OQa N 800--ao 1-�/,
W
6.Is(are)the well(s): h ermanent or ❑Temporary Signature of Certified Well Contractor t�Date
4v signing this form,!hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or ISA NCAC 02C.0100 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:
S.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 ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
dulled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` (ri J (ft.)
For multiple wells list all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:.
+�S_ 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft) Information Processm" Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" g ,�.
'11.Borehole diameter: 611 (in) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)'
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air 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 producing over 100 000 GPD:Copy to DWR CCPCUA
Air Per Program,1611 MSC,Raleigh,NC 27699-16
13a.Yield(gpm) Method of test mrt 11
pp
13b.Disinfection type: Sterilerle Amount: 1)1f e �p-s
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018