GW1-2023-01422_Well Construction - GW1_20230208

WELL CONSTRUCTION RECORD (GW-1). For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Conhactor Name
FROM I TO I DESCRIPTION
2464-A I q,& 1539 a Z) -u
NC Well Contractor Certification Numtber f
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO - I DIAMETER THICKNESS MATERIAL
ft. fL I in
Company Name
2.Well Construction Permit#: � U t/rl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits Ct.e.UIG County,State,Variance,etc.) +1 ft; 6 1/8 in• SD R-21 PVC
3.Well Use(check well use): it l/ft
Wate=Supply Well: FROM _ TO DIAMETER S SLOT SEM THICKNESS MATERAL 1
❑Agricultural ❑ cipal/Public is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
❑Indust ial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000GPD FROM TO MATERIAL EMFLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 it' 22 rt Be6tonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑_Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
O O❑GGotheimal(Heating/Cooling Return) FROM TO DES Ncolor hardy so�7/ etaOther(explain under#21 Remarks) fL p fL
4.Date Well(s)Completed: /� Well 1D# 41/jft -�C7 ft st
i
PHLtiocaon• -7 UJft- ft S L
_ li n/ /� #afl)
L
Faciflityy//Ojwwnnerr Name �� Facility ID•##(if applicable) ^� ft. ft. "
l0_a //' �91 PO ���,1(/sU� o<�VV ft ft. FEB
Physical Address City aayp��ZZip ft. ft o �••?� r 1 '
County fi u Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,
Qone,latllo17 is sufficient) �/ r 1 22.Ce ' catio
3503U ,31 N 800 /J I �7 W Z
1�—
6.Is(are)the'well(s): ermanent or ❑Temporary Signature of ed Well Contractor Date
By signing this jorm,lherebv certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o I 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:
S.For Geoprobe/DFT 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:9.Total well depth below land surface: 24.SUBMITTAL INSTRUCTIONS
� (ft,)
For Inultt'ple wells list all depths if different(example-3@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: / (ft.) 24a. For All Wells: Original j form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,16 7 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in) 24b.For Injection Wells: Copy to DWI;,Underground Injection Control(IUC)
Air D ri I I Program,1636 MSC,Raleigh,NC 27699-1636
(L.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i e.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: Copy WR,CCPCUA
24d For Water Wells producing over 100.000 GPI: Co to D
13a.Yield(gpm) � Q Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
;� Gd 13b.Disinfection type. Ste rilene Amount: 9� S
i
Form ow-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018