GW1-2022-00857_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO� DESCRIPTION
Well Contractor Name ft :GS " 2 d
2464-A ft. ft.
NC Well Contractor Certification Number p
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERAAI.
ft ft in.
Company Name ^
2.Well Construction Permit#: o1D_ 3 `!/,C-7 FROM TO / DIAMETER TIICIMSS MATERW
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft, y( fC 6 1/8 in SDR-21 PVC.
3.Well Use(check well use): Ll tt L1/� ft G J C
0 Water Supply Well: FROM 1 TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'tv OAgricultural O clpaUPublic ft ft in.
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Olndustrial/Commercial OResidential Water Supply(shared)
❑hri ation OWells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
p3 Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
yu ❑Monitoring ❑Recovery tt ft.
Injection Well: ft ft
OAquifer Recharge OGroundwater Remediation
9J OAquifer Storage and Recovery ❑Salinity Barrier FROM I MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology 0Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer ' s
tam
FROM TO DESCRIPTION color,ha ess,soilfrock a etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C) tt `� ft ✓D W M) I
4.Date Wells)Completed: /� Well ID# 10 fr. / ft
3 fL tt `p fp
Sa.Well Location: G
ft ft j'. �77 f"I I�:--F
Facility/Owner Name Facility ID#(if app icahle) 9 [ft. ft
S/f e -2 Gl/ Q l'' It— tt
Physical Address,City,and Zip ft ft.
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 72.Certifi ation:
35o3 ,IF N 800 -a�
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ed ell Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well' ❑Yes or 01 o 15A NCAC 02C.0100 or 1 SA NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis 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:
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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �/ it.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6" (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
(i.e.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
13a.Yield(gpm) Q Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
136.Disinfection type: Sterilene Amount: C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018