GW1-2022-04035_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPI70N
2464-A ft. s'U
NC Well Contractor Certification Number
QSILI otltitu7tL ells to li
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name
,
2.Well Construction Permit# �•Cy�/ / FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well cons'rucitonpermits{i.e.UIC.,county,stae.Variance,etc.) t1 ft. ft- 61/8 in SDR-21 PVC.
3.Well Use(check well use): fc Z ft. - i.
Water Supply Well: 6 FROM TO I DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
BGXQ M
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft- Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
9�SAZII)5G_.,.[]Aquifer
i1 _icati e
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Storrnwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer D aD.Ri' dtwriattnhe "'�
❑Geothermal FROM TO DESCRIFI'10 color,hardness,soUrock 'n size,etc.
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 tt
4.Date Well(s)Completed: :1 _ Well ID# Ll 0 ft. 70 ft. s r
5a.W 111 Location: 70 ft- 2 ft,
�'1�Il-sty'/t'v�' `,,��/ll.'/ C�-•Zft. �� /�rid�'d w/t� `� ��{� G°L
Facility/Owner Name Facili ID9(if applicable) ft. ft.
777
Ph 1 Address,City, Zip
ft. ft.X !
-- G t -
� �43 1 -
Uzv
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i' „
(if well field,one laulong is sufficient)
35� � �� -�� / �� r/ 22.Certifi n: , , •� Jt
L ` N $O W
6.Is(are)the well(s): 014anent or ❑TemporaVo
Signature of Certifi ell Contractor 'Date.
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 15A NCAC 02C.0100 or 15A 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 1121 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 I 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)
For multiple wells list all depths ifdierent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/fwater level is above casing,rise"T g � g ,
IL 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 producint=over 100,000 GPD:Copy to DWR,CCPCUA
//�� Air Permit Program,16]1 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4J Method of test:
13b.Disinfection type: Sterllene Amount: 1"Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018