GW1-2022-06032_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRUnON
2464-A ft. cl ft
ft• ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICIaYFSS MATERIAL
Company Name ft. ft. in.
� � �r� _ - - -----
2.Well Construction Permit#: FROM TO DIAMETER THICIQVFSS MATERIAL
List all applicable well construction permits(i.a UIC,County,State,Variance,etc.) t1 ft. fL 6 1/8 in' SDR-21 PVC
3.Well Use(check well use): ft. n.
Water Supply Well: FROM
TO DIAME ERJ SLOTSIZEy THICKNESS GMATERIAL
❑Agricultural ❑ rclpal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared).
OhTigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENr MUMOD&AMOUNT
Non-Water Supply Well: 0 ft• 22 ft Bentonite lHole Plug
❑Monitoring ❑Recovery ft, ft.
Injection Well:
ft❑Aquifer Recharge ❑Groundwater Remediation ft
_ _
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM o TO MATE RIALe EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer - -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To D ArM N co ,hardn soitrock s�ern
�f ft ft
4.Date Well(s)Completed: v ell ID# S2 ft- 7 ft•
5a�_ e11 Lo n p � ft. ft
Facility/Owner Name Facility ID#(if ap q �/ ff ft —`-
L rCJ G. ft fL `
Physic Address,City,and Zip ft ft
County Parcel Identification No.(PIN) I n �i���ii t t lu i 7 I'i'tJ .lzii5 5 cif
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) Q �^ ' fs`r
`' 22.Certifi n
35�' N 80O, N W
6.Is(are)the well(s): errnanent or ❑Temporary Signature of certitiodwell 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 o ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair•fill out known wel!construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under k21 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 c
9.Total well depth below land surface: 5 ft)
For multiple wells list all depths ifdifferent(example-3W00'and 2 10 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level.below top of casing: ( ) 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
11.Borehole diameter: 6n (in-) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill '
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water SuoDly 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 aroducint=_over 100 000 GPD•Copy to DWR,CCPCUA
ISP ) �?, Method of test:
13a.Yield m �?. Air Pertmt Program,1611 MSC,Raleigh,NC 27699-161]
13b.Disinfection type: Sterllene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6r6-2018