GW1-2022-08962_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
-
TO DESCRll nON
Well Contractor Name
2464-A S F P 'ti 2022
it
. ci
NC Well Contractor Certification Number i i 1 .,,, ;r., U - —
3
Frank A. Corriher & Sons Well dFlilmg, rl'c��-�= FROM TO DIAMETER TffiCKNESS MATERLAL
ft ft in
Company Name ZY1 n �]5 MATERIAL FROM TO D—
2.Well Construction Permit#: ( 1AMLr1ER TlnclavEss
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) +1 ft ft 6 1/8 I tn (�i 12
SD R-21 PV
3.Well Use(check well use): Auft. 2 fill. 1
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public ft ft. in.
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) ft ft.
❑lndustrial/Commercial ❑Residential Water Supply(shared) -
hri ation ❑Webs>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AmouNr
on-Water Supply Well: 0 ft 22 & Bentonite Hole Plug
\ ❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
° ❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO IMATERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer o _
❑Geothermal(Heating/Cooling Return) ❑Other(e lain under#21 Remarks) FROM To DESCRIPTION cola,hatdnes; rock t5ae etc)
® `� Jul ft it
4.Date Well(s)Completed:b 0'✓ 9� Well ID# Va ft -f t
5 Well Locaho
Facili�tyf f t/9 rName Facility ID#(if applicable) ft. ft.
/o-Ll i✓f/ D�i it ft.
4
Physical Address,City,and Zip ft. ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) / 22.Certification: 1
35 Q3 GO` � N 80©- � � 9 W
6.Is(are)the well(s): kf'er lanent or ❑Temporary SigaatuXe of ell tontractbr Date
13v signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15.4 NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fdl 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: 0 (ft) I'
Submit this1
For multiple wells list all depths ifdii ferent(example-3©200'and 2@100) GW- within 30 flays of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
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 +' I I
6" 24b.For Injection Wells: Copy'to DWF.,Underground injection Control(IUC)
11.Borehole diameter: (4) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24a For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger.rotary,cable,direct push,etc.) county environmental health department of the county where installed
- I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
� V
13b.Disinfection type: Sterilene Amount: CQ
1 �
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I I