GW1-2022-06419_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCR n__,
2464-A i rift j Yv fL Q
NC Well Contactor Cettifieation Number ft• ft
i
Frank A. Corriher& Sons Well Drilling, Inc. DIAfR Tmcl�v MATERIAL
FROM TO
Company Name �i /�J' ft h- is
2.Well Construction Permit#:�/Jt_/ fj y RROM TO DiAME�)R -
List all npplhnble well construction permits(I.e.UIC.County,Stare.Variance,etc) t 1 ft TUCm
ft 6 1/$ 'a' � n>wTeR>AL
3.Well Use(check well use): 2 ft. R. -
SDR-21 PVC
Water Supply Well: C
❑Agricultural FROM TO DIAMETER SLOfS¢E THICIQVESS MATERIAL
❑ 'cipaUPublic ft. ft. I is
❑Geothermal(Heating/Cooling Supply)
idential Water Supply(single)
❑Indusnial/Commercial ft R
❑Residential Water Supply(shared),
❑ on ❑Wells>100.000 GPD FRoM TO MA[BRiwi
Non-Water Supply Well: P METHOD&AMOUNT
U ft- 22 �- Bentonite Holeole Plug Plug❑Monitoring ❑Recovery
Injection Well: ft. n
R
`Aquifer Recharge ❑Groundwater Remediation ft'
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MATF.RIAI, EMPLACF1yENr❑Aquifer Test ❑Stormwanx Drainage et. R MMOD
❑Experimental Technology ❑Subsidence Control ft. R.
❑Geothermal(Closed Loop) ❑Tracer -
OGeothermal ooling Renun) ❑Other( lain under#21 Remarks) FRoM TO D o color, soihoek
n ® n. !0 &
4.Date Well(s)Completed: d Well ID# V7 R �,? g,
Well Location: 2 y fL fL r
R. ft.
Facillity//Owar Name 9 FacilitY ( aPP lD0 ifa
ft. fL
fL
Physical Address,City.and Zip ft. ft.
County Parcel Identification No.(PIN)
tMlii
5b.Latitude and longitude in degrees/minutes(seconds or dermal degrees:
(if well field,one lat/long is safficiem)
A 22.Certifi n:
80p -a�- �` w n
6.Ware)the well(s): 64anent or
❑Temporary Sigrtamte of Certifi ell Contractor
Date
7.Is this a repair to an existing well: Oyes or By signing dus form I hereby cer16 that the well(s)was(were)constructed in accordance with
if this is a repair•fill out brown wdl construction irfomwtion and exp/mn the nature o the I record men or ISA NCAC 02C.02001Ve1!Construction Standards arid thku c copy
repair under 421 rcmarls section or on the back of this join. j Prmided to the well owner,
8.For Goo 23•Site diagram or additional well details:
probe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this construction,only I GW-I is needed. Indicate TOTAL NUMBER ofwells (add'See Over in page to provide additional well pages ifpon info
drilled: Remarks Box).You may also attach additional pages if
9.Total well depth below land surface: t 24•SUBMITTAL INSTRUCTIONS necessary.
For Multiple weth Bat ali depths tfd erent(example-3 .200'a»d 1(<>a/00) (fL) Submit this Gw-I within 30 days of well completion per the following:
10.Static water level below top of casing: 24a. For Ali Wells: Original
ljwater level is abow (R•) Information four . Division of Water Resources (D )
ntg,use�`� Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11•Borehole diameter: 6" An-) 24b.For Injection Wells:Co D
PY to WR,Underground Injection Control(fUC)
lz Wellcoastroction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(Le.wJM minty,cabk,direct push,etc) 24e.For Water SuDDIv and Open!Loon Geothermal Return Wellc county envrronmezltal health deparb;te;t of the coon COPY to the
FOR WATER SUPPLY WELLS ONLY; ty`Where installed
24d.For Water Wells Drodnciu¢lover lO0 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:.Air Pexinit rrogram,161 I MSC,Raleigh,NC 27699-1611
13L Disinfection type: Sterllene Amount: T li
Form OW-1 North Carolina Deparanent of Environmental Quality-Division of Water Resources
Revised 6-6-2019
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