GW1-2022-03104_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCR ON
2464-A �" z6o ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DLfhiETER THICKNESS MATERIAL
ft. ft. in.
Company Name Q 1
2.Well Construction Permit#: ''i n I v 3 1 aS a- mom To D►AMErER THICKNESS mATEeuL
List all applicable well construction permits i.e.U1C,County,State.Variance•etc.) t1 ft. ft. 6 /$ in. SCR-21 PVC
3.Well Use(check well use): R (o fL Lin,
O Cil�
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ cipaUPublic fL ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
fL ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
OIrrization ❑Wells>100 000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNf
Non-Water Supply Well: 0 R• 22 ft Bentonite Hole Plug
FOAquifer
g ❑Recovery
ell:
Recharge ft' ft
g ❑Groundwater Remediation _
orage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEN[MErHOD
st ❑Stormwater Drainage M ft.
pntal Technology ❑Subsidence Control tt
ft.
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothermal(Heating/Cooling Rearm) ❑Other(explain under#21 Remarks) FROM TO D� N color tu.aness.sov,od
.-v iti�—
4.Date Well(s)Completed: r —a ell ID# ft. � R i qy//q�� )Yn
5a.We Location: ?� ft. R• O
s��� e ft. /314
FacilitylgYwner Name ft.
Facility ID#(if applicable) ft.
,r4 �,o���i%�� -► �sv,%IP ft. & MAR 7 20 ?
Physical Ad"City,and Zip R ft
Cory Parcel Identification No.(PIN) pr MIMI pwas
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IwAong is sufficient) i 22.Certifi n
35p ' " N 80© --5� 11 3,�
W 1 3/-
6.IS(are)the well(s): ermanent or ❑Temporary it Signanue of Certifi ell Contractor Date
a repair to an existing well: ❑Yes or o Q,11/V/ BY signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this 15A NCAC 01C.0100 or 15A NCAC 01C.0200 well Construction Standards and that a copy
If th/s is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided to the we/!owner.
repair under k21 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-I is needed. Indicate TOTAL NUMBER of Wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.drilled:
^ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (i! (�)
For tmt/rtple wells fist all depths ifdiff¢renr(example-3@20o'and 2�I0o� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: (�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing rise"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
l I.Borehole diameter: 6" (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
'
24c
(Lt.auger,rotary,cable direct push etc.) cou For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY�LLS ONLY: 24d.For Water Wells Droducin¢over 100 000 GPD Copy to D
Pro WR,CCPCUA
139.Yield(gpm) Method of test:Air Perm"' gram,161 I MSC,Raleigh,INC 27699-1611
13b.Disinfection type: Sterilene Amount: C
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018