GW1-2022-04057_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal se Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTIOx
2464-A 9©f` F °
ft. ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM -ft ft TO DIAMETER THIC104M MATERIAL
Company Name '7 n�,( /��J _
2.Well Construction Permit#: O ` t � l FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State.Variance,etc.) t1 & fL 61/$ 'n- SDR-21 PVC.
3.Well Use(check well use): ® fL Zft. 4,
Water Supply Well:
IAMETER CKNESS MATERIAL❑Agricultural ❑ icipal/Public FROM TO ft. ft. D in.
SLOTSIZE THI
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. fa in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
OIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
Non-Water Supply Well: 0 ft, 22 Bentonite Hole Plug
❑Monitoring ❑Recovery k. fL
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT'METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology []Subsidence Control fL fa
❑Geothermal(Closed Loop) ❑Tracer -
❑Geothennal(Heating/Coohng Return) ❑Other(explain under#21 Remarks) FROM I To DESCR ox color,hardness,saitf rk type,grain etc
e) 0 ft. ft.
4.Date Well(s)Completed:O' ON Well ID# 5-0 ft.
Sa.Well Locatio -Lft. YE:A
oc
�. 0 ? ft ft.fj
Facility/Owner N/e fc/ility 1DN(ipf appli�cab
ft k ft.
:' m'-..�
i"
Physical Address,City,and Zip fL ft. 029
1 �r12�
County Parcel Identification No.(PIN) .�;.,. `'•,• {i-i L�''�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
( 5u fine latiflong is sufficient) / � 22.Certifi n•
N 800"3q w _
6.1s(are)the well(s): C1Permanent or ❑Temporary Signature of CertiS ell Contractor per`
By signing this form,I hereby cert�that the wells)was(were)cons trucled in accordance with
7.Is this a repair to an existing well: ❑Yes or V. 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJPubs is a repair,f!l out known well construction it formation and exlilain the nature of the of this record has been provided to the well owner.
repair under 921 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-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-)
Far multiple wells list all depths ifdi ifrent(esa nple-3 00•and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: J C. (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
so .(in) 24b.For Iniection Wells:Copy to
11.Borehole diameter. DWR,Underground Injection Control(IUC)
Program;1636 MSC,Raleigh,NC 27699-1636
12.Wellconstructionmethod:Alr Drib '
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producine over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gP m) thodoftest:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
Me
13b.Disinfection type: Sterilene Amount:—ea— n
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources es Revised 6-6-2018