GW1-2022-00876_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -- - -
FROM TO DESCRIPTION od
Well Contractor Name
2464-A ft ft-
ft. ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM '° DIAMETER THICKNESS MATERIAL
ft ft in.
Company Name - -
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permiz-fr.a.Un-,Coa—nq,State,✓araace tL ft is,etc.) +1 (hj 6 1/8 SDR-21 PVC
3.Well Use(check well use): © ft. L ft
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ 'cipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
t ❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 22 n- Bentonite Hole Plug
V ❑Monitoring ORecovery it. ft
Injection Well:
O [t fL
❑Aquifer Recharge ❑Groundwater Remediation _..... _... _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
OExperimental Technology ❑Subsidence Control ft. ft.
V ❑Geothermal(Closed Loop) ❑Tracer _
❑Geothermal(Heating/Cooling Return). ❑Other(explain under#21 Remarks) FROM TO DES ON color,b ess wa/rouc axe as
ft ft GJNJ
4.Date Well(s)Completed: ` / Well ID# ft t0 ft
5a.Well Locati//qn: ,/ It ft
q17�[ l� 1A Im• s a/ fL fL _
Faciillliity//`Owner Name/ Facility M#(if applicable) f4 fL -
f:a
Physical Address,City,and Zip C/
1 QQ ` ft. ft.
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce cation:
3 8 ` Nsoo - �gf ay11
� W
/2
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ed ell Contractor Date
kv 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 V. /SA NCAC 01C.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:
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 ( 'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l J (ft.)
For multiple 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:
I10.fxnter level is above casing.use"+" 2 0 24a. For All Wells: Original!form to Division of Water Resources (DWR),
Static water level below top of casing: (B) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ
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:AI r Drill
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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,'00 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Q Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount C
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018