GW1-2022-06033_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIFIION
2464-A ft �p d ft. t Sr c
ft. ft.
NC Well Contractor Certification Number
,�OII1=lEB` S G'!'fox�fu']t'�"""..'swells`.R�IHE r€•a- ica61e _
Frank A. Corriher& Sons Well Drilling, Inc. FROM T
ft. O DIAMETER in. THICKNESS MATERIAL
Company Name
ft.
eo- aEcTosedSou 7�
Z.Well COnS[rUCtiDII Permit#:_ I FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable'veil constructionpetrims(i.e.UIC,County,Sate, Varionce,etc.) t� ft. ft. 6 1�$ in- SDP-21 PVC.
3.Well Use(check well use): L in. 1/
Water Supply Well: reGRFt _O
FROM TO DIAMETER SLOTS IZE THICKNESS MATERIAL
❑Agricultural Vesidential
cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single)
0 ft. ft. in.
❑IndustriaUCommercial ❑Residential Water Supply(shared) --
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 1t. Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge it• ft.
v`\ 9 ❑Groundwater Remediation
v fGHeY, GIC;rFa'licamxe .:❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIALEMPLACEMENT.. 3'
v] AfETHOD
❑Aquifer Test ❑Stormwater Drainage ft• ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) []Tracer
eluailaitidrialisnee -
r:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFSCRIPI ION coror,nanass s soi/ ck rvn size etc
49
4.Date Well(s)Completed: 7� Well ID# Q ft•
5a. I Location: a ft. t•
C- - i �2 t. t
Facility/Owner tie Facility,1D#(if applica / t ft. ft.
ft. ft.
Physrcal ddress,City,and Zip ft. g• �.aT
County Parcel Identification No.(PIN) WMEM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !V:Pill,`a i KT-1
(if well field,one lat/longissufficient) I': ':7vdSil�i' k ii;j' Lii.If\I1
35CO I ! f/ 22.Cl ifi n:
6.IS(are)the well(S): ft�lYermanent 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 ISA NCAC 01C.0100 or ISA NCAC 01C.0100 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 921 remarks section or on the back ojthis 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: �t
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ffi)
Pot multiple wells list all depths if di fferent(example-3Q200'and 2 100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: _(ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ijwater level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: " (in.) 246.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply a d n Oe pn-Loop Geothermal Return Wells Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department oe county where installed
FOR WATER SUPPLY WELJ.,S ONLY: f th
b 24d.For Water Wells producinfl over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) a Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
t
13b.Disinfection type: Sterilene Amount:
Forth GW-I North Carolina Department of Environmental Quali
ty ty-Division of Water Resources Revised 6-6-2018