GW1-2022-01130_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name fL Z 3 C/
2464-A ft.
NC Well Contractor Certification Number
Frank A. Corriher&Sons Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. ft. tn.
Company Name ^ /- Q
2.Well Construction Permit# rr/�� FROM To DIAMETER THICKNESSMnrERInL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) +1 ft fL 6 1/8 i" SDR-21 PVC
3.Well Use(check well use): r,d ft. 2 ft.
Water Supply Well: FROM TO DIAMETER I SLOTSIZE I THICW`1ESS MATERIAL
❑Agricultural icipaUPublic ft ft. in.
❑Geothermal(Heating/Cooling Supply) ecswential Water Supply(single) ft IL
❑IndustriallCommercial ❑Residential Water Supply(shared)
01rrieation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MEPROD&AMOUNT
Non-Water Supply Well: 0 ft- 22 fL Benton'Ite Hole Plug
❑Monitoring ❑Recovery ft. fr
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL Eh1P[ACEMENr METHOD
❑Aq uifer Test ❑ ry Storwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
FROM I TO DE§OWON color, ness,so type, sia.etc
❑Geothermal(Heating/Cooling Return) ❑Ctther(explain under#21 Remarks) ft
4.Date Well(s)Completed: /Well II)# 1� fL ,_&
5a.Well Location: fL L t. &-k ra
7&o V 1417 ft. ft.
Facility/owner Name Facility ID#(if applicable) fL ft.
Physical Address, ,and Zip �7 � 7�� � ft. AN 0 3 2022
CQ Gt lk.s
County Parcel Identification No.(PIN) UNI
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: pl Nic
(if well field,one lat/long is sufficient) 22.Certify lion:
35 o / 3/ // N so d a 4/-�23 ( W
6.Is(are)the well(s): @!Permanent or ❑Temporary Signanre of etl Contracmr Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V0 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: / 7�/ 5- 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ (ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001
�/1� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7s (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level Is above casing,use"+"
" 24b.For infection Wells:Copy;to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well caustruction 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
/� Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 V Method of test
13b.Disinfection type: Sterilene Amount: Cops
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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