GW1-2022-06484_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIPI'fON
2464-A 12E l 2"' 7
ft. ft.
NC Well Contractor Certification Number _
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name /
ft. ft. in.
2.Well Construction Permit#: FROM TO DIAMETER SS MATERIAL
E THICKKNN
List all applicable well construction permits(i.e.UIC County,Slate, Variance,etc.) +� ft• ft. 6 1/8 i^ SD PVC
3.Well Use(check well use): O o fa
Water Supply Well:
❑Agricultural
FROM TO DIAMETER ft. in. SLOTSIZE THICKNESS MATERIAL
❑M cipal/Public ft.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared),
❑lrri ation ❑Wells>100.000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft. Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well:
❑A uifer Recharge ft• ft.
q ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier r sa lr e -
h' FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer u ifWonalbee
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DFse Io (calow nardn s soi/rock n sia etc.
ft. ft.
4.Date Well(s)Completed: ;7~ Well ID# ft• G O L
5a.Well Location: ?—I'- ' zo ft.
-/ #qAe -9j16 ft. ft.
Facility/ ter Name �cility 1D#(if appficablej') /�� fL ft. ._ `
h n a, oG(� ft. fL
Physical Address,City,apd�Zip �� � ft. ft.
G /// `�O -... 4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(if well field,one latAong is sufficient) 22.Certify n�
35 N 80p•.-t�9 "c�� W ����
6.Ls(are)the well(s): ermanent or OTemporary Signature of Certifi ell Contractor Date
By signing this form.1 hereby certify that the wells)was(were)cons trucied in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and chat a copy
if this is a repair,fill our known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under P,21 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-I 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: 0,0.5- (ft.)
Tor multiple wells list all depths ifdtoerent(example-3@2000'/'and 2@100) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: Q(t� O 24a. For All. Wells: Original form to Division of Water Resources (DWR),
lfwater level is above casing,rise"-" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
n .(in) 24b.For Injection Wells:Copy to D
11.Borehole diameter: 6 WR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Alr Drill
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return ells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Ills Water Wells Droducin,!over 100 000 GPD100 000 GPD•Co to D
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-16L1 Copy �'R CCPCUA
13b.Disinfection type: Sterilene Amount:
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018