GW1-2022-03059_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
7FROM
TO DESCR�I70N
We1lContractorName / ft.M.
2464-A 6 ft.NC Well Contactor Certification Number ----Frank A. Corriher& Sons Well Drilling, Inc. TO DIAMETER' TH1ClOVESS MATERIAL
ft. in.
Company Name � —
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well consttvclion permits(i.e.UIC,County,State,Variance,etc.) t 1 fL / It- 6 1/8 i" SDR-21 PVC '
3.Well Use(check well use): C ft' 6 2 ft' '4, a/(/
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural J.1id
ipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft• ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) BGID
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. se.
❑Geothermal(Closed Loop) ❑Tracer 'Db` ddiEio h
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,solfmcktype,grain sim eta
4 ft. ft-
4.Date Well(s)Completed:�. /Q•_ ��Well ID# '5-0 ft. / � ft. S `
2-ft- �� t• d—Sa. ell Location: c
�h 100-� xossel ft.
F/Facility/OwnerName
yy��g/��,�` t Fac''ty 1D#(if applicablg 1 ft. ft.
Physical Address,City,and Zip ft. ft.
Gao,��ltS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if el�eld,ones sufficient)attlong is su 8r7 Y ! !! 22.Certifi r Ir i t j G UNT
35 N 7V �52 W n�
6.Is(are)the well(s) ermanent or ❑Temporary Signature ofCcrtifipd well Contactor Date f Q`
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 �o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known well construction information and explain the nature of the ojthis record has been provided to the well owner.
repair under I121 remarks section or on the back ojthis form.
23.Site diagram or additional well details:
S.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-I 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: (ft.) Submit this GW-1 within 30 days'of well completion per the following:For multiple wells list all depths ijdi.Qerent(example-3Q200'and 1QI001 P P
130 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use Static water level below top of casing: ( ) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f "+"
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
�} Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) v Method of test:Air
13b.Disinfection type: Sterllene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i