GW1-2022-09138_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name ft e/ ft 30 R
2464-A fL 4L
i
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft tt in.
Company Name 2.Well Construction Permit#: t/t V ^ `'(/J�
O FROM y To DInMETF1i TI110ESIEss MATERUL
List all applicable weU construction permits(s e.[1/C,County,State,Variance,etc.) +finn 6 �8 'n SD R-2 PVC
3.Well Use(check well use):
Water Supply Well: Z'Fait,
TO DIAMETER SLOT STLE TffiCKWESS MATERIAL
❑Agricultural i-le-sidential
rcipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) tt is
❑Imdustrial/Comrmeroial ❑Residential Water Supply(shared) Fee
❑1ni lion []wells>100,000 GPD TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 fL Bentt nite Hole Plug
❑Monitoring ❑Recovery M ft
Injection well: ft it.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft M
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color h!LtM aoOlroek VIM Vrain size,eta.
❑Geothermal eating/Coolmg Return) ❑Other(explain under#21 Remarks) 0 ft AD M
4.Date Well(s)Completed: - Well ID# 2-L it ft'
5a.Well Location: / 3 it
a- C p ft. its.
ft ft
Fae''ty// er Name Facility ID*,if applicable)
` 11 G44 G ft it , —
Uni
Physcaln dress,City, ip it R
Physical Inivci �n�1 )'i ca?iaS ntJ i
i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laf/long is sufficient) 22.�Ccatio
6.U(are)the well(s): CdPermranent or ❑Temporary Signature of led Well Contract f Date
13v signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is,this a repair to an existing well: ❑Yes or o 1 SA NCAC 02C.0100 or 1 SA 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.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (fL) Submit this GW-1 within 30 da s of well completion r the folio
For multiple wells list all depths if different(example-3©200'and 2Q10&) y mP Pe following:
10.Static water level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+'If Processing Unit 1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in) 24b.For Injection Wells:Copy to DWR Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r D rl I I 24¢,For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county envronmental 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
13a.Yield(gpm) Method of test:Air
Permit Programs,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: cterllene Amount: �� $
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018