GW1-2023-02948_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher FROM TO DFSCRILeLTON
Well Contractor Name ft 121)fL 1l
2464-A- ft ft
NC Well Contractor Certification Number
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO n R 7MCHNESS MATERIAL
ft ft In
Company Name3906 _
2.Well Construction Permit#: FROM To DIAME eR TlnclavEss MATERIAL
List all applicable wit construction permits(r e.UIC,County,Stark,Variance,etc.) +1 ,- ft- ft 6 1/ 1O SDR-21 PVC
fL
3.Well Use(check well use): _
Water Supply Well: FROM I TO DUMETEt SL.OTSIZE, THLCIGiESs MATERIAL
❑Agricultural ❑ -cipal/Public ft ft
❑Geothermal(Heating(cooling Supply) esidential Water Supply(single) ft ft in.
❑lndustrial/Commereial ❑Residential Water Supply(shared) e
r
❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT MMOD&AMOUNr
r Supply Well: 22 ft Beritonite Hole Plug
ng ❑Recoveryft ft
Well: ft ft
Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLAL EMPL KEMENT METHOD,
❑Aquifer Test I' - ❑Stormwater Drainage ft tt
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer
FROM TO I DE29UMON color,hardness,soillrook sire,etc)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) f- fL �
4.Date Well(s)Completed: ;Well M# rN OR fL
O Et z ft 1 S
5a11 Location: p °f d
Fac' / N F iGry ID#(if pliwble)
tt ft a... _ ....�,t
s + ft ft l t -.. 1
f�a�r��5f�o/� ft. ft.
P lAddress�,andZ� " o� � � 2023
768
- It40t ;:: ion Prac:�airog Ur.�
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat long is sufficient) ; 22.C Lion-
35p li N 800 `c3� � l t' W - Z/—
6.Is(are)the well(s): ermanent or ❑Temporary Signanue of Ce ed well nttactor Date
BY signing this form,I herebv certify that the xvll(s)was(were)constructed in accordance with
7.Is this a repair to an eiisting well: []Yes or o 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a cop,
Ifdds is a repair,fill out Imowo well construction information and explain the nature of the ojthis record has been provided to the well ovine{
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 nece nary.
drtlled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` 00 Submit this GW-1 within 30 days of well completion per the following:,
For multiple wells list all depths ifdifferou(example-3 200 and 2@100)
of casing: 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top g (D-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If rater level is above casing,use"+"
6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (�) 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
(i-e.auger,rotary,cable,direct pusb,etc.) county envuonmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing over 100,000 GPD:Co to D
13a_Yield(gpm) q� Method of test:AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy WR,CCPCUA
13b.Disinfection type: Sterllene Amount• I e-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised&&2ois