GW1-2022-03697_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIMON
Well Contractor Name v ft
2464-A ft. ft.
NC Well Contractor Cer iScation Number - -
MATERIAL
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MnrERIAt
fL ft. in.
FROM
Company Name DIAMETER THICKNESS
_
2.Well Construction Permit#: TO
List all applicable well construction permits ir.e.UIC,County,State,variance.etc.) t1 ft. ft 6 1/8 In- SDR-21
3.Well Use(check well use): 3`� fL 3 t1 fL IAS
Water Supply Well: FROM TO DNMRRj SLOTSIZE THICKNESS MATERIAL
❑ p cultural ❑Kesidmitial
t al/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.i
❑Industria/Commercial ❑Residential Water Supply(shared)
❑lrri lion ❑Welis>100,000GPD FROM TO MATERIAL EMPLACEMErfrMEMOD&AMOUNT
INN
Non-Water Supply Well: O f° 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation _ _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft. fL
OExperimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer
OGeothermal(14eating/Cooling Rewm) ❑Other(explain under#21 Remarks) FROM D mrto rotor,eardn soibrock sia etc
ft. ft.
4.Date Well(s)Completed: Well ID# ft' ft ;1 tiri
5a.Well lion: .3 ft. ft t
r re t ft. fL
Facility/Owner Nam Facility ID#(if applicable) ft. fL
Physical Address,City,and Zip ft ft
&t--g/I aim
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.:;M�
35a,3 ',j f, N 800 ��13 ;� w 2-?- -aa
6.Is(are)the well(s): 01ermanent or ❑Temporary Signature of CertifiOVell Contractor Date
l/ By signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
7.is this a repair to an existing well: ❑Yes or k4 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
If 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 021 remarks section or on the back ojthis 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 I GW-1 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
p F f !j (example- y p per the follow'
For multiple wells fist all depths r di Brent exam le-3 0 'and 2 J00 ��
24a. For All Wells: Original form to Division of Water Resources (DWR),
if waterlevel is above casing,use Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ij
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
(Le.auger,rotary,cable,direct push,etc.) courtly 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) Method of test:Air !
�+ oC.Ga G' 'a i—
136.Disinfection type: St@rll@rle Amount: s `
MAR 2 9 202?
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 66-2015
r,.