GW1-2022-07143_Well Construction - GW1_20220804

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher - imam M_
FROM TO DESCRIPTION
Well ConuactorNatne
2464-A [(/ft ft.
NC Well Contractor Certification Number —- -
Frank A. Corriher& Sons Well Drilling, Inc. 11TO DIAMETER TIICIams I MATERIAL
ft ft is
Company Name /i<���
2.Well Construction Permit#: tom}/-OS/ J,�/') FROM TO DIAMETER 7SD
OCIavFss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft ft 6 1/8 to R-21 PVC
3.Well Use(check well use): 9t it-
Water Supply Well: FROM TO DIAMETER SLOTSIZEMMM
1HICKNFSS MATERIAL
❑Agricultural ��,id!ti
al/Publ' it ft 1�.
❑Geothermal(Heating/Cooling Supply) al Water Supply(single) ft ft is
❑bidustrial/Commercial ❑Residential Water Supply(shared) 4
❑hTi ation ❑Wells>100000GPD FROM TO MATERIAL EMPLACEMENTMETEOD&AMorINT
Non-Water Supply Well: O 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: - it ft
❑Aquifer Recharge ❑Grotmdwater Re mediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft IL
❑Experimental Technology ❑Subsidence Control ft %
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) FROM TO DES ON color,hardness,solltrock size,etc;)_ v IL ye D:t--�
4.Date Well(s)Completed: `u�( ell ID# Y() ft -a o ft 5 q,
5a.Well Location: 5­0 ft ftik a-.
G
Facility/Owner Name Facility ID#(if applic!![[ >// ' ft ft
Oer�!ACC ft ft
PhVjcal Address try,and Zip ft ft R
County Parcel Identification No.(PIN)
'li)1Ci91iaalail pfOC.4ir7,li"�5�(f fS:j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one la``t/long is sufficient) 22.7ation:
350D � N 800 -;O ' 17 W 7/fir
6.Is(are)the well(s): iBPermanent or ❑Temporary Signature o ell Con6ac[or Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1 SA NCAC 02C.0100 or 1 SA 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 thisform. 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.
wed' J �( 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / U (ft.) Submit this GW-1 within 301da s of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2(I Me) y p P
10.Static water level below top of casing: Q (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+„ ng: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 61' Qn.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,,NC 27699-1636
12.Well construction method:Air Drill
24c.For Water Supply and Opea-Loop Geothermal Return Wells:Copy to the,
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over'00,000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) � Method oftest•
13b.Disinfection type: Sterilene Amount: CQAJr,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018