GW1-2022-08405_Well Construction - GW1_20220829

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name /0 ft ft Id
2464-A ft ft.
NC Well Contractor Certification Number -—
Frank A. Corriher& Sons Well Drilling, Inc. OM TO DrnMrrrR THICKNESS M,.TER�►L
ft ft tn.
Company Name 9r t
FROM TO DrAML"= TRICKINESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i_e.UIC,County,State,Variance,etc.) +1�/�/ ft73 ft ft (/ IL 6 �$ in ----- PVC
G(� s � v
3.Well Use(check well use):
Water Supply Well: FROM To I)MM£TER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 'ideirtial
cipalftblic ft ft in
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
FoAquifer
n ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACts'MENT METHOD&AMOUNT
er Supply Well: O rt 22 Bentonite Hole Plug
ring ❑Recovery ft ft
Well: ft _ ft
.� Recharge ❑Groundwater Remediation r
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATT IAI EMPI ACENtEN r MEIHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer _
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To nEs Ox color, .o E.Mk sae ere)
© ft- 5 d [t
4.Date Well(s)Completed:7 � ell ID# �� ft ft 5
(� Srll Locati;t r
Facility/Owner Name Facility ID#(if applicabltJ7(�a ft tAUG t
�, o0��66�` Fa 1
© U� G �ifrG�� ft ft u u L �G
Ph Address,City,and Z' ft ft Iftivi'r'i i3uD 1 i'i>C w:J.?3 ()Ri:
1//
�.
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Ce 'on:
35� � " N 80t'I'•- ..- w � 4eOA' 4zZA 't��
6.Is(are)the well(s): ermanent or ❑Temporary, Sigoat of well Contractor Date
h v signing this form,I hereby certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ��q. 15A NCAC 01C.0100 or ISA 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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below to of casing: O� (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
P g Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above caring,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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: p�
13b.Disinfectiontype. Sterllene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018