GW1-2022-09174_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM 1'O DESCRIPTION
Well Contractor Namerd
2464-A it it.
NC Well Contactor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER TMCKNESS I MATERIAL
ft. fL tn.
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Company Name -
2.Well Construction Permit#: f OM TO DIAMETER THICKNESS MAXERIAL
List all applicable well construction permits(t.e.UIC,County,St e,Variance,etc.) t 1 ft fL 6 1/$ tM SDR-21 PVC
ft. ft � Oy /
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiC[QVESS MATERIAL
❑Agricultural 'cipaUPublic it ft
❑Geothermal(Heating/Cooling Supply) es❑M identi.1 Water Supply(single) n It. !in.
❑Indushial/Commercial ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100 OQO GPD FROM I To MATES EMPI.ACEME T METHOD&AMOUN
Non-Water Supply Well: 0 ft. 22 ft Bentonite Hole Plug
0Monitoring ❑Recovery ft. ft.
Injection Well: it tt
❑Aquifer Recharge ❑Groundwater Relnediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERML EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control . it
❑Geothermal(Closed Loop) ❑Tracer
FROM ,TO DESCRIPTION(color,badness,eon/roek ere.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it
ft 6
4.Date Well(s)Completed:c/—!Fr-.9'Q Well ID#
Wale
5a Well Location: 3
ft. ft
ttll'on���a��e �a�/1
Face'' /Owner Name F ility ID (if applicable ft ft r� �„ •e s fey E P
G S t. ft. tt ft. ft. -
-
Phys Address,City,and Zip
county, Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if well field,one Iat/lQng is sufficient) � /! 22.Zati!Z
35� 1{ y N 800--3, ``5_7 w
6.1s(are)the well(s): ermanent or ❑Temporary
Signature of ell Contractor' Date
i Z
By signing this form,I herebv certify that the—U(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
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:
S.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: / .r 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:- (ft) Submit this GW-1 within 30 days of well completion per the following:
For muklple wells list all depths if different(example-3@200' 1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 9and 2 (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use +'
11.Borehole diameter: 6e (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 rI I l 24c.For Water Supply and 01 en-Lon 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 producine over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 100 Method of test•AI r
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: 2
f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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