GW1-2022-04843_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-I) For Internal Use only:
1.Well Contractor Information:
Ricky Corriher ,_
Well Contractor Name FROM TO DESCRIM N
2464-A o�?�f`' a ft. S
ft.NC Well Contractor Certification Number ft.
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
Company Name in./'�
osed�oo -
2.Well Construction Permit#: 1 OM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(r.e.U1C,County,Stare,Variance,etc.) +1 ft. ft. 6 1/8 in• SDR-21 PVC
3.Well Use(check well use): ft. -ze) ft. J in.
Water Supply Well: -- _
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public tt. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared):
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
y Non-Water Supply Well: 0 f� 22 It- Bentonite Hole Plug
❑Monitoring ❑Recovery fe. ft.
(� Injection Well:
❑A uifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Sailor - A i ahle _v_ ;. _— RN
tY Barrier FROM TO MATERIAL EMPLACEMENr METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft.
C , ❑Geothermal(Closed Loop) ❑Tracer o arc�.a�ach�adumorra€shieers, aeces - —
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soiVroc n size,eta
ft. ft.
4.Date Well(s)Completed:S 3al ell ID# j tt• 7 ft. (D �,J
5a.Well Location: 2 e9 ft.
aQcility/Ow'nneer Name F cility 11)#(if applicable ft ft. '►� ,,; "
Physical Addre� City,and Zip ft. ft.
�' aif✓-�t,�rt�S
County
Parcel Identification No.(PIN) 1e�,i.;b3ti;7 r�v J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
� /► ` J 2 (/ 22.certis
35 n:
��� 3U Q N $OC7 �' (� W
6.Is(are)the well(s): Oermanent or ❑Temporary Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC o2C.020o Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis 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-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:- (fL)
poi multiple wells list all depths ifdierenr(example-3@2000'n'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing:.. pf,� (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,ruse"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter. 6" (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 2'7699-1636
12.Well construction method: 24c.For Water Supply and ODen-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 producing over 100,000 GPD•Co to D
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13b.Disinfection type: Sterilene Amount: C
op
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018