GW1-2022-04862_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher —
FROM TO DESCRll'ITON
Well Contractor Name �R. ?49
.
2464-A PAP
NC Well Contractor Certification Number
s oSll!I arm h _
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
ft. ft. in.
Company Name �-� t __,__�
2.Well Construction Permit#:-+I-/ r j G' I Q// FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.Ul ' aunty,Srare.Variance,etc.) +1 ft. ft. 6 /$ in. SCR-21 PVC
3.Well Use(check well use): ft. Z ft.
Water Supply Well: FROM I TO I DIAMETER I SLOTSSIZE I THICKNESS MATERIAL
❑Agricultural ❑M rcipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) in.
[Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 22 ft. Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
Set I)7G 3f i 11 a b
❑Aquifer Storage and Recovery ❑$alinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 11bR11V d adiiifioniif�alieeti
❑Geothemral(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEscRrPrl N color ardnms,soi/rock in sia,etc
4.Date Well(s)Completed:_�Well ID#
Sa.Well Location:
SOLIY7 / ft.ft. ft.ft.
i T ..f'
Facility/Owner Name Facili 1D# if applic
(i.Mz
�t� ft. ft.
Physical Address,City,a d Zip
_ Y�s ry�y
County Parcel Identification No.(PIN) +XR'-"'?�' '� pp�LL3'c%1+'}�7 1101 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if 35��one lat/lon is su tctent) o O / 22.:M�/Z"z
r "� J N C7 ?`,�3 W O�
6.Is(are)the well(s): e/.anent or ❑Tempora�./
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 NC AC 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 P21 remarks section or on the back ofthis 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: V (ft.)
por multiple wells list all depths ifdii fdrent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
D 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
lfwater level is above casing,use"+"
11.Borehole diameter: 611 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai Drlll
24c.For Water Supply and Open-Loop Grmal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the eothecounty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producins over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,161 I MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount: .
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018