GW1-2022-09137_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher ---
FROM TO DESCRLPTION
Well Contractor Name 21 .2n�
2464-A ft. `�
i
NC Well Contractor Certification Number - .-a.
Frank A. Corriher& Sons Well Drilling, Inc. OM DIAMETER THICKNESS MATERIAL
tL ft in.
Company Name FROM TO DL4ME
2.Well Construction Permit#: 7 TER TjucxivEss MATERIAL
List all applicable well construction permits t.e.UIC,County,State,Variance,etc.) +1 �7 ft tL 6 �8 ;y 1° SDR-21 PVC
3.Well Use(check well use): - ft. S C f
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCIINESS MATERIAL.
❑Agricultural ow
cipaMblic fL fL in.
❑Geothermal(Heating/Cooling Supply) esid-eiZI Water Supply(single) g• fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 22 tL Bentonite Hole Plug
❑Monitoring ❑Recovery fL ft.
Injection Well: ft. ft
Q J ❑Aquifer Recharge ❑Groundwater Remediation ._
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft tL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer '0 atta o
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color hardness,soWroek type,grain s' eta
(� t!:;, tL "Yt7 It. 4)Gv
4.Date Well(s)Completed: Vl/ Well ID# w m
5a ll Locatio l > 30 &AE'
fL ft.
Facili /Owner Name —o Facility ID#(ifapplicable) ft ft
w fL fL HE 3 2022
Physi_I Addyess,City,and Zip ft. tL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ItUlong is sufficient) / 22.Ce ation•
35(� Q ' N 80p-QS --
w
6.Is(are)the well(s): 0 ermanent or ❑Temporary Signature of Ce ed Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or lti 0 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copv
If this is'a repair,fill out known well construction information and explain the nature of the of this record has beer.provided to the well owner.
repair under#11 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 39 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdifferent(example-3©200'and 2@100) Submit this GW-1 within 30 days 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
Ifwater 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
(i.e.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) (C Vop Method of test: f
n
13b.Disinfection type: Sterllene Amount:
Form GaW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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