GW1-2022-09175_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name ( r{t � I
2464-A ! ft j
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM 1O 'ffi M"'
ERML
ft ft.
L
Company Name 3 MATERIAL
FROM TO D
��J
2.Well Construction Permit# ? IAMETER IHICiSS
List all applicable well consavcnon permits fie.UIC.County,state.Variance,etc.) +1 `4L;S n 61/8 it°n SD R-2�1i PVC
3.Well Use(check well use):
Water Supply Well- FROM I TO DIAMETER SLOT SEM TMCKKM MATERIAL
❑Agricultural O aUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) identiat Water Supply(single) ft ft in.
❑lndustriallCommencial ❑Residential Water Supply(shared)
❑ ❑Wells>100,000 GPD F1tOM TO MATS EMPLACEMENT'MEMOD a AMOUNT
Non-Water Supply Well: 0 ft' 22 ft Bentonite Hole Plug
DMotlit:,
❑Recovery ft ft
Injection Well: ft ft
OAq�er Rech�e ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMTLACXMMXTNWrHOD
OAquifer Test O Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control D- ft.
❑(eothermmal(Closed Loop) ❑Tracer
FROM I TO DES CRIYrrON color,hardness,saiYnoetctype,Vmrmante,etc)
OGeothermal eating/Cooling�g Reetum,.) oother(explain under#21 Remarks) n D �
4.Date Well(s)Completed:C _ Well ID# it t{ fL
5a.Well Location:
ft- "'Os I�L� �- LO�t#'2G
n ft ft
L a K (��� ft ft
FacTiillfty/OJw�nnefierrNNNalme Facility
MJ(ifapplicab i _
ILk 7/57da�4
ft. ft
P City,and Zip '-7 _
f<e aw �� -
co� Parcel ndfication No.(PIN) b
Ur,
5b..Latitude and longitude in degrmstminutes/seconds or decimal degrees:
(if well field,one laTng is sufficient) y+�.l 22.C ratio
35�s-3 y N 8U®-3��'�Z`J W6, k `1�-
6.h(are)the well(s): ermanent or ❑Temporary Sigoatrue of ed Well Contractor Dare
IN signing this form.I hereby certify that the weU(s)was'(were)constructed in accordance with
7.U this a repair to an esisting well: OYes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0200!Nell Construction Standards and that a copy
If this is a repair,frU out known well construction information, ezplain die nature of the of dhis record has been provided to the well owner.
repair under#21 renarks section or on the back of this form. 23.Site diagram or additional well details:
S.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.
drilled: 24.SUBMITTAL INSTRUCTIONS
/7
9.Total well depth below land surface: (i`�' (f,) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells fist aU depths ifdilferent(example-3Q200'and 2@100)
24a. For All Wells: Original ifohn 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 inter level is above easing,use"+"
11.Borehole diameter:60 (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 I 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
13a.Yield(gpm) Method of test:
Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount~
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018