GW1-2022-10244_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A ft 4C Go
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM DIAMETER MCK?>;ss MATERIAL
it- it UL
Company Name
2.Well Construction Permit#: oJ` FROM To DL,uv>ETER 'ITUCEMM MAT137W— ,
List all applicable well construction permits(Le.UIG County,State,Variance,etc.) t 1 R [t 6 1 8 tn' SDR-21 PVC
3.Well Use(check well use): Q li ft I in
-e
Water Supply well: FROM TO DIAMETER SLAT SIZE THICKNESS IMATERIAL
❑Agricultural ;?.id.ipaUPublicft. ft. in.
❑Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
Oh-rigation ❑Wells>100,000 GPD oM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fG 22 ft Bent6nite Hole Plug
❑Monitoring ❑Recovery IL ft
11 Injection well:
}' ft [t
❑Aquifer Recharge ❑Groundwater Remediation T.-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
V ❑Aquifer Test - ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return) ❑Other(explain tinder#21 Remarks)
FROM TO ft DEScoloress sailtrockbve.grain size,etc.
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\, 4.Date Well(s)Completed: t —I/` Well ID# (qJ•� it ,29 tc (�
5a.W ll Location: C� fi �/2—ft. O
Facility/Owner Nano Facility ID#(if applicable)
n ft.
4, Z on Oin ✓ DYPS / ill G �l fti
Yual Addre,s,City,and Zip � � It.
tt
7-
County Parcel Identification No.(PIN)
I�w�:+o�Prxa
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ff well field,one lat/long is sufficient) / 22.C catio
35 �� /� N 800 L��.- w
6.Is(are)the well(s): P 10
ermanent or ❑Temporary Sigoattue of ed Well Contractor Date
�� Ay signing this form,I herebv certify that the wvll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or Y""" 1 SA NCAC O1C.0100 or 1 SA NCAC O1C.0100 WeU 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 remarkr section or on the back of thisform. 23.Site diagram or additional well details:
8.For GeoprobelDPT 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-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
Willed' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (N Submit this GW-1 within 30 days of well completion r the folio For mt&ple tvelis list aU depths if different(example-3 00'and 2@100) Y mp per wing:
30 ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing:
lfwvar level is above casin&use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6° (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Well construction method:Ai r Drill
(La24c.For Water Supply and Open-Loop Geothermal Return Wells•Copy to the
(i e.auger,rotary,cable,direct push,ern.) 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)_30 Method of testAi r Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
c
13b.Disinfection type. Sterilene Amount: _
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-&2018
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