GW1-2022-03695_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTIONr� �yl ft �I t ft � �
2464-A !/�" ft. !J ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM To ft. DIAMETER THICKNESS MATERIAL
ft. in.
Company Name
_ os.
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well consiruciionpermits(i.e.UiC,County,State, Variance,etc.) +1 ft. fL 6 1/8 i" SDR-21 PVC.
3.Well Use(check well use): C7 fL 2 ft- S /�
Water Supply Well: FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.:
❑lndustrial/Commercial ❑Residential Water Supply(shared) - MO
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMEM METHOD&AMO[1NT
Non-Water Supply Well: 0 fe. 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. I ft.
❑Experimental Technology ❑Subsidence Control fa ft.
❑Geothermal(Closed Loop) []Tracer orb - na h
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPn N color,badness,soiltrock in size,etc
© ft. IV ft. e t_./L
4.Date Well(s)Completed: - - Well ID# ft 5 ft f)
5a.Well Location:
s-s-� ft.
4t(��� -3 t-C G(-'nA
Facility/Owner Name Facility ll)#(if applicable) ft. ft.
69 o moores ,'ll rl�/7w[/ o /Ie s il; k
Physical Address,City,and Zip
a tit-Q./f
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.:=��
_
/ �1 �y� �� W
35 N $6Q - ,
6.Is(are)the wells) ermanent or ❑Temporary Signature of CertifiadVell Contractor 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 o 15A NG4C 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifibis 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 P21 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: u�j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /✓ (ft.)
For multiple wells list all depths ifdii ferent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
/l 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: f/ (ft-)
fL) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter: 6" (in) 24b.For iniection Wells:Copy to 1DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill 24c For Water Supply and Open-Loop Geothermal Return Welts: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 GP):Copy to DWI;,CCPCUA
AI r Permit Program,1611 MSC,Raleigh,NC 27699-1
13a.Yield(gpm) Method oftest: 611
13b.Disinfection type: Sterllene Amount: 3 A
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources VAR 2 9 ZOL..^7 Revised 6-6-2018