GW1-2022-06154_Well Construction - GW1_20220623

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A
ft. ft.
NC Well Contractor Certification Number
OT 'B;. SIFI�Gi�focuiu']tceasc�'�elts`OR`IsTNIsR�tfa'"Itca e— —
Frank A. Corriher& Sons Well Drilling, Inc. I FROM TO DIAMETER THICKNESS MATERIAL
Company Name / ,
__ _. ft. in.
FROM t� `SI]tiTA.Rir1<.l7B11 ... berm os
2.Well Construction Permit#: O DIAMETER THICKNESS MATERIAL
List all applicable well construction permits t.e.UIC,County,State,Variance,etc.) 1 t1 ft. S" ft• 6 1/g '^
G� SDR-21 PVC
3.Well Use(check well use): ft. ft. h i OL L,
Water Supply Well:
FROM TO w DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑ icipal/Public ft.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared),
Fate
❑Wells>100,000 GPD FROM TO L MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 0 tt. 22 e• Bentonite Hole Plug
g ❑Recovery ft. tt.
ell:echaz a ft.
g ❑GroundwaterRemediation orage and Recovery ❑Salini Barrier 'f$—licah e , -
h' FROM To
MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 1101DRII1T1 :ach^sdd;t,ona��lieetaeces
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DFsc IPTION color,hardness,soLrock n s ze eta
8
4.Date Well(s)Completed: ; ell ID# ft. 6e) ft.
5 Well Location: aft. ft. S.
/ ft. e�stt.
Facility/O ner Name Facility 1D#(if applicd6l j ft. ft. 4"� „� r C SI
O'r/LS 10 ft. It.
Physical Address,City,and Zip
County
Parcel Identification No.(PIN) t+;%`:>o'^^':�Te^`1 v� i.."��;�N✓�l i,�l I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if
35well
a` -on //ent) QO^' 1 11.Certifl n•
�—N—C7 V.— /
6.Is(are)the well(s): "e/.nent or ❑Temporary Signature of Certifie<rwell Contractor Date
By signing this form,I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or � 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards amf 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 1111 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-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: (fG)
For multiple wells list all depths;jdiJjerent(ex;
3@200'and 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),
If water level is above casing.use"=" 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)
Program,1636 MSC,Raleigh,NC 27699-1636
Il 12.Well construction method:AIr Drill "
(i.e.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 producint=over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gP m) 11,5 Method oftest:Air Permit Program,1611 MSC,Raleigh,NC 27699-16 11
13b.Disinfection type: Sterllene Amount: 5
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018