GW1-2022-09176_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DFSCRnMON
Well Contractor Name
2464-A 2k ev
ft ft
NC Well Contractor Certification Number -- —
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER— TH>�sS MATERIAL
tt ft in.
Company Name 1/nA' w`1t �'1/f - -
2.Well Construction Permit#: v I v FROM TO DIAMETER TIDCIQTESS MATERIAL
List all applicable well construction permits(t-e.UIG County,State,Variance,etc.) +1 ft � ft 6 1/8 � SD R-21 PVC
3.Well Use(check well use): (p ft ft W-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICENESS MATERIAL
❑Agricultural ;?esidrntial
clpal/Public ft ft in.
❑Geothermal(Heating/Cooling.Supply) Water Supply(single) ft ft in.
❑lndustcial/Commercial ❑Residential Water Supply(shared)
70AqLdAfer
' n ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
er Supply Well: 0 fL 22 ft Ben tonite Hole Plug
ing ❑Recovery ft ft
Well: ft ft
Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier I TO MATERIAL ]12dPLACE31ENTMKMOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
V ❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hastnessAothock Mm,grain size,etc
s^� 0
0 ft �/[J ft -S I K
4.Date Well(s)Completed-(7 jyWell ID# b ft �.� f" 1 Oc-)C
5a.Well Locatio 3 f t 1 d- 1✓1
Facility/Owner Name Facility ID#(if applicable ft ft.
A t/i' �e >9v ft >t F P 3 n 2 -
Phys% Address,city.and zip ft ft
23—
O Una
D
County Parcel Identification No.(FIN)
�5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
35>�►one lattlong;s sufficient) 80!� j��� 22.c `li7-
6.1s(are)thewell(s): Q
N W
ermaneut or ❑Temporary Signature o fied Well Contractor Date
li v signing this form,I hereby certifv1that the—11(s)was(were)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or ;r' 15A 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 this form.
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 ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
wed' 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 multiple wells list all depths if different(example-3@200'and 2@100)
(� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: UC (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
11.Borehole diameter:
6" (in) 24b.For Infection 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
(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 27699-161,1
13a.Yield(gpm) C/ Method of test:
13b.Disinfection type: Sterilene Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018