GW1-2022-04042_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name
FROM TO DESCRIPTION
2464-A lift l�fL
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#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIG County,State,Variance,etc.) t 1 ft. ft- 6 1/8 in- SDR-21 PVC
3.Well Use(check well use): fL fL in.
Water Supply Well: FROM TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑ clpal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tl, ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) =-saw
❑Irri ation ❑Wells>100,000 GPD MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • Bentonite Hole Plug❑Monitoring ❑Recovery L
Injection Well: L
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer - -
N
❑Geothermal(Heating/Cooling Return) �f❑Other(explain under#21 Remarks) fL 6 fL s FROM TO DESCRIPTIO cobr,hardusoifmck si e,err;L
p� 4.Date Well(s)Completed:v-C�043 Well ID# Wit. fL 0 Wit
}} V ft. t.
ls� Sa.Well Location- 7 3�{ 16 Cce G
,i ow,12 1�e_a ft. ft.
Facility
//Owne
err
�Na�m�e/� �I ,,�q(/ st Fa^cilit//�ID#(if appli fL fL
bn C/l�(/�/ P�/ Otn117 �V G/V1 tLC'� �yl, fL fL r^'
Physi ikddress,City,and Zip fL fL r a •a.j:l`•,
�'i 1-1�O G,D®2_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lon�sufficient) �! 22.CertiS ni ;
35&Z3 6�a N 80 � �f
6.Is(are)the wells) ermanent or ❑Temporary Signature of Certifi ell Contactor Date
By signing this form./hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or t6x,. 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 Y.21 remarks section or on the back of this farm.
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: t%l fL
For mulriple wells list all depths ifdi¢rem(example-3(200'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),
/fwater level is above casing,use"-
f Static water level below top of casing: (ft•) Information Processing Uni 1617 MSC NC 27699-1617
- rg t+ ,Raleigh.
11.Borehole diameter:6" (in) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(L.Well construction method:AI r D rI I I 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
(Le.auger,rotary,cable,direct push etc.) county environmental health department of the county where instal led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produrinQ over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Stenlene Amount: 3-!-a W-S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018