GW1--03141_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPIION
Well Contractor Nair L) ft 7 0t 0
2464-A- ft. ft
NC Well Contractor Certification Number _
Frank A. Corriher&Sons Well Drilling, Inc. FROM it it in TO DIAMUrm THICKNESS MATEM L
Companyxame /J5,
2.Well Construction Permit FROM To DIAMETER THICt4HFSS MAtFtttet.
List all applicable well construction permits(t.e.UIC,County,state,variance,etc.) +1 ft 69 ft 6/1/8 in SD/R--i21 PVC
3.Well Use(checkwell use): --
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑A.g[ilcultural ❑ utncipal/Public ft ft in.
❑Geothermal(Heating(Cooling Supply) Residential Water Supply(single) ft ft in.
❑lndustrialfCotmmercial ❑Residential Water Supply(shared)
OlTrigation ❑Wells>100,000GPD FROM TO MATS EMPLACEMENTMETHOD&AMOUNT
FEJAquif"
Water supply Well: 0 fL 22 ft Bentonite Hole Plug
nitoring ❑Recovery ft ft
tion Well:
it it
Recce ❑Groundwater Remediationifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACII41EN1 METHOD
❑Aquifer Test
❑Stormwater Drainage fL ft
❑Expetim®tal Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
FROM TO D ON only hitdaem soilftoefc ems,eta)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remaz3ss) ey fL C, fL
ry fL ft.
4.Data Well(s)Completed: WellID# —( v
5a.Well Location-
ft ft
�JL 11 Prallo er 9023
Facility/ erName n [� to / 7Faariliry1D# f
(ifapplicable)) f ft tMAY -0
info
P1rysV-y Address.Cky,and Zip ,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.C Vtio
3503el f N 80 0 --a 9 °- Jay W
6.Ware)the well(s): chfermanent or ❑Temporary Signature ofCohiTed Well Contractor Date
orm.I hereb that!/ By signing thi fy cerdfv the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or k . 15A NCAC 02C.0100 or 15.4 NCAC 02C.0100 Weu Consavuion Standards and chat a copy
YtW is a repair,fiR out,blown well construction information and explain dte nature of the of this record has beet provided to the we11 owner.
repair under#21 re tarkt section or on the back of this form. 23.Site diagram or additional well details-
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells ( See Over'is Remads Box).You may also attach additional pages if necessary.
ddUed= / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / —(fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple welb list all depths ifdffferent(example-3 a200'and 2@100�
�] 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: et ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing;use +
IL Borehole diameter.6- (m) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigh NC 27699-1636
12.Well construction method:AIr RR V rlIi 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i-e-angler.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,CCFCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 v/�/ Method of test:
13b.Disinfection type: Ste rl Ie n e Amount: S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-fr2018