GW1-2022-06870_Well Construction - GW1_20220719

,I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DES ON
2464-A ft• l
NC Well Contractor Certification Number _
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name ��� �y� _. ..-F --- ---
2.Well Construction Permit#: ©Q% FROM TO DIAMETER I THICKNESISM TERIAL
List all applicable well construction permit f.e.UIC,County,State,Variance,ere) +1 ft ft 6 1/8 1° SDR-21 PVC.
3.Well Use(check well use): . t ac 9 ft-
Water Supply Well: FROM TO DIAMETER! SLOTS SIZE THICKNESS MATERIAL
❑Agricultural ;e1sid..1tial
cipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft.
in
❑Industrial/Commercial ❑Residential Water Supply(shared). -----
oh-rigation ❑Wells>100,000 GPD FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft• 2 ft• Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
❑A uifer Storage and Recovery ❑Salini Barrier C8 `9ry ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft- ft.
❑Experimental Technology ❑Subsidence Control ft. fL
I
❑Geothermal(Closed Loop) ❑Tracer - a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. L O ft DEs ox mior, ess,mihnek sine,ere
4.Date Well(s)Completed: 'CJ Well MN /D ft ft•
Sa.Well Location- /^ 'r ft.
R/ in Low ft. ft. e y
Facility/OwrrerName Facilityft ft I 2O2_
(ifapplicable L 7
v
Physiq Address,City,and Zip ® ft. ft ti:ir+i S<<lo1 fi t'
im
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees•
(ifwell field,one lat/long is s�Tent)
r 22.�CeZrtffln
35 N 80er-�7` VO , W
9--?7
6.Is(are)the well(s): ermanent or ❑Temporary Signature of Certifi ell Contractor pym
By signing this form,[hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®1Yo 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and dwi a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ofthis 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:
�} 24.SUBMITTAL INSTRUCTIONS
/
9.Total well depth below land surface: c� (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'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),
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)
Air Drill
(Le.auger,meaty,cable,direct push etc.) Program,1636 MSC,Raleigh,NC,27699-1636
.Well construction method: 24c.For Water Supply and Oben-Loon Geothermal Return We'is'
ls Copy to the
(i county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells aroducinta over 100,000 GPD•Co D
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh',NC 27699-1611 Copy to CCPCUA
13b.Disinfection type. Stenlene Amount C
, I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 6-2018