GW1-2022-09135_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO N
DESCRD'1IO
2464-A ` D °c
[t ft
NC Well Contractor Certification Number.
Frank A. Corriher& Sons Well Drilling, Inc. FROM ft. TO ° THI acgESS MATERLv
m.
Company Name - —
Z.Well Construction Permit#: ,
1 l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) +1 fL R 1/8 to SDR-21 PVC
3.Well Use(check well use): 3 it eft e
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MwrERLAL
❑Agricultural ❑Kesid
aUPublic ft ft in
❑Geothermal(Heafmg/Cooling Supply) tial Water Supply(single) D ft in.
❑lndustiialtCommercial ❑Residential Water Supply(shared)
❑Irri *on []Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft- Bentt nite Hole Plug
❑Monitoring ❑Recovery it ft
Injection Well: ft ft
DAquifer Recharge DGroundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM i TO MATERIAL EMPLAt�NTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heatiag/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRD'110N cobr hardness,aoillroet etc
\` it n
(v 4.Date Well(s)Completed: � Well W#• ft y� ft S U
5a.W ocation: f�
ft ft , 1� V 4
Facility(Owner Name F` / D#(if applicable ft ft
iti ft _. s v
Pbys Address,City,and Zip ft it {nM Ala �:1 ;'i D��3&.•g6fl UR:I
�-q,)2Ob.1f U-5
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 on
j
3503I �' � N 800t --6 61 W
6.Is(are)the well(s): rmanent or ❑Temporary Signs of ed Well Conttactoii Date
Av signing thisform,I hereby certify that the wvll(s)was(were)constructed in accordaxce with
7.Is this a repair to an existing well• ❑Yes or o 15A NCAC 02C.0100 or I5A 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 this form. 23.Site diagram or additional well details-
8.For GeoprobeMPT 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.
filled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V (R•) Submit this GW-1 within 30 days of well completion r the following-
For For multiple wells list all depths iirdifferent(example-3@200'and 2@1001 con P per wmg:
F
3 24a. For All Wells: Original!form to Division of Water Resources (DWR),
10.Static water level below top of casing: O Ijwuer level is above casing.use Information Processing Unit,16 i.j7 MSC,Raleigh,NC 27699-1617
••+••
11.Borehole diameter: 6" (in.) Program,
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 Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct posh,etc.) corm environmental health department epartment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells producing_over 100 000 GPD:Co to D
13a.Yield(gpm) Method of test:
Air Permit Program 1011 MSC,Raleigh,NC 27699-1611 Copy «x CCPCUA
13b.Disinfection type: Sterilene Amount-
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018