GW1-2022-01152_Well Construction - GW1_20220103

WELL C ONSTRI CTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIPTION
2464-A -70 oft .a
fL ft
NC Well Contractor Certification Number _
Frank A. Corriher& Sons Well Drilling, Inc. FROM To D_ THICKNESS MATERIAL
ft
Company Name
2.Well Construction Permit#: t�f FROM TO DI,* TER TmCICMS MATERIAL
List all applicable well construction permits(i.e.UlC,County,State,Variance,etc) +1 ft ft- 6 1/$ "L SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: FROM I To DIAMETER sLOT size THIclQVEss MATERIAL
❑Agricultural 0 cipal/Public ft. f. in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL tt in.
❑Industnal/Commercial ❑Residential Water Supply(shared)
ObTigation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water supply well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft.
ft.
Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer
❑GeOtlleim'ia1(Heating/Cooling Return), ❑Other(explain under#21 Remarks) FROM TO DESCREMON color,hardness,soWrock etc
ft ft
_ 1
4.Date Well(s)Completed:U-ice a Well ID# Yo ft ft
5a.Well Location: _ ' t l 4.--
ft ft
Facility/Owner N Facility ID#(if applicabl?�f/� ft. ft.
13 :SPrj �c� oo�-S�"%lP (� ft ft 0 3 2M
Physical Address.e and
Zip 7192 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) 22.C cation:
35p'3 7 � `� N 80o ,y9 � �0 // W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of C ed ell Contractor Date /
By signing this form,!hereby cerufv that the we (s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MVo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a copy
1f 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
filled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / ,J (ft.)
For multiple wells list all depths ifdierert(example-3@200'and 2 a@1001 For this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Ify Static water level below top of casing: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1j»mter level is above casing.use„+„ g P,h,
11.Borehole diameter: 6° (�) 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
(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 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018