GW1-2022-07142_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A ft
NC Well Contractor Certification Number
"t '� 4
„15�:pC1�RSIl�6�fo�utullr�ace we�'10, >C�"�a'�ics-
Frank A. Corriher& Sons Well Drilling, Inc. k(RoM I To I DIAMETER THICKNESS MATERIAL
ft. ft. in
Company Name
c �R�A"S� O1��LC1PI���,,"enhe• c os -o
2.Well Construction Permit#:3 a t7 FROM TO DIAMETER THICKNESS 0 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) +1 ft. ' , ft. 6 1 f$ in- SDR-21 PVC.
3.Well Use(check well use): T2 it 7 rt 1 ��
(1 , Water Supply Well: ls
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ZJ
ipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) CLRO --
❑hri atioa ❑Wells>100,000 GPD FROM TO MATERIAL Y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt 22 rt Bentonite Hole Plug
U ❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑A uifer Recharge it [t
4 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 'fe livable
ty er FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage it ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
�2 +I1�`.. - 8tt8'C�I�lti6 r9 Ee�si��'CCCSS ..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESC TION colo hardn soivrack a size etc
m �— tt •2
4.Date Well(s)Completed: �� �� Well ID# ft rt S
5a Well Location: ft. 3 f it p,
Fac�ility/O%wnerName // /�F ilitgy�ID#(ifapplica �/ % ft
U / q t 3 11,,71�l/�X &b�!rf�CY/ r- rt tt
Phemal Address,City d p ,/ n
� � rL _ ttAUG 'Cf 2L122
County Parcel Identification No.(PIN) f� ��Uri
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 'ration:
35 N 80 W
�?O_ 00
6.Is(are)the well(s): k ermaaent or ❑Temporary Signature ofCe Well Contractor, i Date
By signing this form,I herebv certify that the 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 ISA NCAC 026.0200 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:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
i�10.Static water level below top of casing: 24a. For All Wells: Ori_ (ft) ginal form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+" Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in,) 24b.For Injection Wells:Copy Ito DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 2
Air Drill I 6994636
(i.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
(ie.auger,rotary,cable,direct push,etc.) county enva onmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells produciae over 100 000 GPD Copy to DWR,CCPCUA
13a.Yield m Air Permit Program,1611 MSC,Raleigh',NC 27699-1611
(gP ) Method of test:
13b.Disinfection type: Sterilene Amount: C
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018