GW1-2022-03699_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Ricky Corriher -
Well Contractor Name OM TO DESCRIPTION
2464-A ft. 1 ft. 2 U .
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
2.Well Construction Permit#: Ica•., l `"J, FROM 1.TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft. Z) ft. 6 1/g in. SDR-21 PVC
e
3.Well Use(check well use): U fL •.' s' 1 i 4'
Water Supply Well: sm
FROM I TO DIAMETER SLOTSIZE THICINIISS MATERIAL
❑Agricultural ❑eeidential
icipal/Public ft. ft. in.I
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. fe. in.''
❑lndustriallCommercial ❑Residential Water Supply(shared) -
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 22 Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
tca
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
❑Geothemtal(Closed Loop) ❑Tracer d' h
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRUrnON color,hardness soi/rock type,Zriiin size,etc.
v/ ft. ft.
4.Date Well(s)Completed: Well iD# 1)ft. ft. S c"t
ft.
Sa Well Location: 2ft.
9/ ,
r
y &-2ft. ft.
Facility/Owner Name ( Facility 1D# if applicable) ft. ft.
=0 Uz Z\Cf el cJ �a o G g&
ft. ft.
Physic ddress,City,and Zip ft. ft.
In
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.Certifi n
350 `� N80o --37- 7� � W 3
6.Is(are)the well(s): k ermanent or ❑Temporary
Signature ofCertifiodWell 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 !SA NCAC 02C.0100 or ISA NCAC 02C.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 of this record has been provided to the well owner.
repair under till 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' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lo-5" (ft)
For multiple wells list all depths ifdii ferem(example-3(,200'and 22@100� Submit this GW-1 within 30 days of well completion per the following:
�V 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (it) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"*
11.Borehole diameter: 6" (in,) 24b.For iniection Wells:Copy toIDWR Underground Injection Control(TUC)
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 productng over.100,000,GPD:Gopy.to DWR,CCPCUA
nl Air Permit Program,1611 MSC,Ral�igh;,NG'27699-1611'
13a.Yield(gpm) V Method of test:13b.Disinfection type: Sterllene Amount: cado MAR 2 9 ?�'7
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ---- ,. . ..,,Revised 6-6-2018