GW1-2022-08951_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
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1.Well Contractor Information:
Ricky Corriher
TO Well Contractor Name f ft DESCRIPTION
t �
2464-A SEP 1 192022 ft ft
NC Well Contractor Certification Number " - __ __
v u� 1 1 'f?C x3 v;:�rJ (FROM TO DIAMETER TRICKINESS MATERIAL
Frank A. Corriher& Sons Well Drilling,Q(Y 1:3o(- ft. ft. is
Company Name -3 75q 7 --
FROM To DIAMETER TKucxivFss MATERIAL.
2.Well Construction Permit#:
List all applicable well construction permits(Le.UIC,County,State Variance,etc.) +1 ft. ft 6 1/$ 1° SDR-21 PVC
ft ft iS Z J
3.Well Use(check well use):
AA
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipaMblic ft. ft. id.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in
❑ladustrial/Commercial ❑Residential Water Supply(shared) ©
❑hri 'on ❑Wells>100,000 GPD FROM I TO MATERIAL I MpLAC11VIENiL METHOD&AMOUNT
Non-Water Supply Well: U ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery % ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTbWMOD
❑Aquifer Test ❑Stormwater Drainage ft R
❑Experimental Technology ❑Subsidence Control M ft
❑Geothermal(Closed Loop) ❑Tracer
FROM I TO DESCRIPTION color,hardness,soiltrock tym grain she,eta)
❑Geothermal(FIeattng/Cooling Return) Zothr explain under#21 Remarks) D ft 113. r y
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4.Date Well(s)Completed: Well DJ# tt �Q fL ^�'G tit
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Sa.Well Location: qq 6 �Y ft
3060Ya o�h a !!
Facility/Owner Name �/ J/J}q�� R/FFaacility ID#(if applicable)
tL
JC �C// J[N/J�)n/f/ !1 •�� ft ft. I
Physical Address,City,and Zip ft. ft.
149
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.C - catio 1
35p�0 /( N 80� 32. — W r 1S ` 2-1-9O
Signature of CeMfied We Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary o p
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
#'this is a repair,fill out known well construction injormatiors and explain the nature ofthe 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 ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) t
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) lnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6" (Jin-) 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 Wra) o Method of test: !
13b.Disinfection type: Sterilene
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Form GW-1 North Carolina Department of Enviroumental Quality-Division of Water Reso i es Revised 6-6-2018
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