GW1-2022-06528_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
Y
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A a? L
ft, ft.
NC Well Contractor Certification Number _
Frank A. Corriher& Sons Well Drilling, Inc. FROM I TO DIAAWrER THICKINESS MATERIAL
ft. ft. in.
Company Name _. _ _ _. _
2.Well Construction Permit#: aq O FROM I TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits .e.UIC,County,State,Variance,etc.) +1 ft ft- 6 1/8 'n' SDR-21 IP—VC
or
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOTSIZE I THICKNESS I MATERIAL
❑Agricultural ❑ icrpaUPublic tt ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared). -
❑lrri ation ❑Wells>100,000GPD FROM TO MATERIAL I EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: O fL 22 1 Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well: ft•
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERUL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it, fL
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer -
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hard- soittock size etc
ft. 3 ft w
4.Date Well(s)Completed ` 10 Well ID# J O fi- 3fL S Oi l
5a.Well Location: ft' 3.2-J• CL z
4V LL ft ft.
Facility/Owner Name_ Facility ID#(if applica ft. fL
�/y ray/ ,//���. _ // p /'//�
/ / i' in rir �/7 Cy4JI Abu.G 46-4��/'J ft ft 4�e'ir� ° �b
Physical Address,City,and Zip fL ft-
C29
air
County Parcel Identification No.(PIN) M,- q '�= a Unit
.r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D%VQt'80G
(if well field,one laOong is sufficient) t? 22.Certiti n:
35(r 3 7 9 "' N 80 0 -30, '4�� W
6.Is(are)the well(s): 64.nent or ❑Temporary Signature of CertifiodVell Contractor Date
By signing this form,I hereby certify that t/te well(s)was(were)constructed 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 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#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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
�j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��-/
For multiple wells list all depths if different(example-3(tt)2�and 2@100) ( ) 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. 6" (in.) 24b.For infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill
(' auger, ,cable,direct push, .) 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le. rotary, etc county environmental health department of the county where installed
FOR WATER SUPPLY LLS ONLY: 24d.For Water Wells producing over 100.000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
/ Program,13b.Disinfection type: Stenlene Amount
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018