GW1-2022-00906_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPf10N
Well Contractor Name J AV ft tt G
2464-A ft ft
NC Wen Contractor Certification Number -- -- -
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO DIAMEM THICKNESS in MATERIAL
ft. ft
Company Name �y / �
�9 ( FROM TO DIAMETER THIC(OVESS MATERIAL
2.Well Construction Permit#: uuua...//� vvv
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) t ft ft 6 /$ '"' SDR/-21 PVC
3.Well Use(check well use): L/
Water Supply Well: FROM TO DIAMETER S[ATSIIE THICKNESS MATERIAL
❑Agricultural omAicipaMblic ft I in.
❑Geothermal(Heating/Cooling Supply) IdEesidential Water Supply(single) ft, ft, in.
❑Industrial/Cornmercial ❑Residential Water Supply(shared) -
01rrigation ❑Wells>100,000GPD FROM TO I MATEERUL EMPLACEMENTMEMOD&AMOUNT
Non-Water Supply Well: O ft' 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery, ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft f
❑Geothermal(Closed Loop) ❑Tracer
FROM
TO DES O arobr, Hess,soi/rsxk era,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ; ft. 6) ft ly A
4.Date Well(s)Completed: D �`�'�� /Well ID# L(J/ ft' ft -- ✓ LA r_y
Sa Well Location: ` vS %A e ki
It
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I�yIT/ �GL✓ L— /l l�le/
Facility/Owner.Name Facility ID#(if applicable)
ft "1
ft ft
PhTiddress,City,and Zip
�wa/7 /30 �
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if weU field,one lat/long is sufficient) 22.CertifT Lion'
3503�' N 80p 3�� g �( W z /oCy�b
6.1s(are)the well(s): Rfl'ermanent or ❑Temporary Sigoatusc of ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or W. 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,Jill out known well construction information and explain the nature ojthe of this record has been provided to the well owner.
repair under 011 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 I 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: f/� (fL) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths tfdtffereni(example-3@200'and 1 a@1001
Ll 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 0 (ft.) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
ljwarer level is above casing,use"*" i
24b.For Infection Wells:Copy to DWR Underground injection Control(TUC)
11.Borehole diameter. 6 (in.) Program,1636 MSC,Raleigh,NC,27699-1636
12.Well canstruction method:Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.sages 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 5 Method of test:AI r
c
13b.Disinfection type: Sterilene Amoant k J
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018