GW1-2022-09476_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD(GW-11 For htemal Use Only:
1.Well Contrac
tor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name
2464-A ft. ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM. To DIAMETER TTuclavFss MATERIAL
YL fL � I in.
Company Name
2.Well Construction Permit#: / ` `� FROM TO DIAMETER TMCIMSS MnTERInL
List all applicable well construction permits(t e.UIC,County,State,Variance,etc.) +1 it ft 6 /8; 1 SDR-21 PVC
3.Well Use(check well use): % ft au• I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultum( ❑ �id
al/Public 1 fL ft ' in
❑Geothermal(Heating(Cooling Supply) tI Water Supply(single) R ft in i
❑Industl:WCommercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMErHOD&AMOUNT
Non-Water Supply Well: - 0 ft 22 ft Bentoliite Hole Plug
❑Monitoring ❑Recovery fL ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMr'LACEMENCMETROD
[]Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer _.
FROM TO DFSCRa'1TON color,hardness
❑G Q ft �--'ta ft
eothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) r7lrock size etc
4.Date Well(s)Completed: / d� Well ID# �fL O IL
f Sa. ell acation: 1 ?� � ,
ft
Facility/Owner Name Facility ID#(if applicable�I ft it ! �..-� 54F, °
fL fL
Physical Address, and Zip > ft R 0 C T 1 _
County Parcel Identification No.(PIN) i' l lhui•t- ,
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if well field one Lu[long is sufficient) /i 22.C oa: 1.
35Qa 5 17 ` N 80 p - _? W
1-22
6.Is(are)the well(s): �rmanent or ❑Temporary
Sigoature of Cert' ell ntractir
By 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 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths ifdifferent(exatnple-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
D�
24a. For All Wells: Original[fib to Division of_Water Resources (DWR),
10.Static water level below top of casing: (ft.)
If water level is above casing,use„+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6„ (in,) 246.For Injection Wells:Copy to DWR,Underground Injection Control(1UC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24c.For Water Suauly and Open-Loop Geoihermal Return Wells:Copy to the
(Le.mug-,rotary,cable,d 'ct push,etc.) county environmental health department of the cotmry where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co to D
Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy �'CCPCUA
13a.Yield(gpm) 'Method of test: / !
13b.Disinfection type: Sterilene Amount: !2 to
North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 6-6-201S
Form GW-1 � P tY �