GW1-2022-08401_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corr iher - - -
FROM TO DESCMInON
Well Contractor Name 7 s"IL 1 ft- 3
2464-A ft %
NC Well Contractor Certification Number -
Frank A. Corriher & Sons Well Drilling, Inc. FROM & To ft D in
rnMETER TMOCNFSS MATRRUL
Company Name � � �� � � -- - '
2.Well Construction Permit#: FROM TO 11MMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft ft. 6 1/a in SDR-21 C.
c/ PV
3.Well Use(check well use): ft it in �� a
Water Supply Well: FROM I TO DIAMETER d SLOT SUE TE ICICWM MATERIAL
❑Agricultural Wlm
l/Public ft ft in.
❑Geothermal(Heating(Cooling Supply) idtial Water Supply(single) ft ft in.
❑Industtial/Commercial ❑Residential Water Supply(shared)
❑1iri atiom ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMouNT
Non-Water Supply Well: O ft 22 fl Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft
❑Aquifer Recharge []Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MA17YJAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
[]Geothermal(Closed Loop) ❑Tracer FROM To DEscRipTlox(color,Onrdness soaltock size etc.)
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Y.,� ft W
00 ft.
nJ
4.Date Wells)Completed:T�= Well lD# ft 3.J ._ .5O k-
5 ell Location: S -� .Geer�-.—,1^C_- F(.T �t,
C t, C�:J Q`'/mi l/ ft ft a _ _...�
ft it
Facile /Owner Name �FacilityID# rfa hcable) .] ruty �GW �I ft ft
rt Ph ft JlnrO/"OMB:
ys' Address,City.and Zip _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) � 22.Ce ca' n:
3501 ' <. N 80© - f �/ W
6.Is(are)the well(s): armament or ❑Temporary tgnature of ed We Contractor Date
by signing this jorm,I hereby cernfv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V. 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe 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 ( '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.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100) y P P g
3
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
6- 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill
24c.For Water Supply and Open-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 Water Wells For over 100,000 GPD100,000 GPD:Copy to DWR,CCPCUA
132.Yield(gpm) 0 Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018