GW1-2022-10604_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
FROM TO DESCRIPTION
Well Contractor Name
2464-A t
tt ft. j
NC Well Contractor Certification Number --
Frank A. Corriher& Sons Well Drilling, Inc. FROM To nIAMETER 1MCKNESs I MATERIAL
ft fL in
Company Name `
2.Well Construction Permit#: �rl�� FROM - TO DIAmsF•rcQ THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC County,State,Variance,etc.) + fL 6 1%8 in. SD R-21 PVC
3.Well Use(check well use): ft ft f �`
Water Supply Well: Pill
FROM TO DIAMETER SLOT SrlE THICKNESS ZMATERIUL❑Agricultural ❑M ' ipaUPublic tt fL inOGeothermal(Heating(Cooling Supply) esidential Water Supply(single) fL ft❑Industrial/Commercial OResidential Water Supply(shared)
❑hri 'on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT'METH
Non-Water Snpply Well: 0 fL 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft. tt
lnjectioa well: M ft
❑Aquifer Recharge ❑Groundwater Remediation .. .._
OAgtufer Storage and Recovery ❑Salinity Barrier FROM I TO 1-1 MATERIAL EMPLACEMF,N'r METHOD
OAquifer Test OStormwater Drainage fL ft
OExperimental Technology OSubsidence Control fL ft
❑Geothermal(Closed Loop) OTracer am lammm
❑Geothermal eating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESNcolor hardoem sonfrotk type.orain Size,etc
Q fL 41,4 ft
4.Date Well(s)Completed:biR U- _ Well ID#
5a.Well Location: ft 2 ft
B^P. ) lY�/1'1�S rL tL
4z2/ N t . n
Facility/Owner Name Facility ID#(if applicableeA
fL ft =
CX r'c,���� ,�� / tL fL 2 202
Physi ddress,City,and Zip A fL ft.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.
pe
350_;-8' Iq N 800:3�`�3� �� W C catio
zlt/4� rOya�
6.Is(are)the well(s): "anent or ❑Temporary Sigranue of d6fiflied Well Contractor �-- Date
B,v signing this form,I hereby terrify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or io /SA NCAC 01C.0100 or 1 SA NCAC 01C.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 undo,#11 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.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 Ovee in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths if different(example-3Q200'and 2@10 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: QC ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
IfwWar level is above casing,use"+ ft luformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in) 24b.For Injection Wells: Copy to•DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,!NC 27699-1636
.Well construction method:Air Drill
(L 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 producine over 100 000 GPD•Copy to DWR,CCPCUA
13a Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 2769 0 r 1
13b.Disinfection type: Sterilene Amount: C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018