GW1-2022-10606_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher - - --
Well Contractor Name FROM TO DESCRIPTION
2464-A i L �y L
ft ft
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAME7ER rfficlavEss mU1ER1A1
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Company Name ^
2.Well Construction Permit#: p'(J FROM TO DIAMETER MCKMs MATERIAL
List all applicable well construction permits rLe.UIC,County.State,Variance,etc.) +1 (L 6 1/8 1D SDR-21 PVC.
3.Well Use(check well use): 3 ff b''�f q [-/`
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIC.X.N.= ZMUATERIAL❑Agricultural ❑M ctpaUPublic, ft ftDGeothernlal(Heating/Cooling Supply) esideatial Water Supply(single) % ft. in.
❑lndusttial/Commercial ❑Residential Water Supply(shared)
❑Itri lion OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METH
Non-Water Supply Well: O ft- 22 ft Bentonite Hole Plug
OMonitoring ❑Recovery ft ft
Injection Well:
ft ft
DAquifer Recharge DGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater.Drainage
fL M
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer
❑Geothermal eating/Cooling Return) ❑Other(explain trader#21 Remarks) FROM TO DES ON co r hardnew sonfrockrim ywoere
4.Date Well(s)Completed: ILIWell 1D# L{v It- 2 fL
Sa Well ocation: Ho
1 / It9-3 IL d^ ��r�.✓o►" c �3 3s fL6 I Lc je, a- w
Facility/Owner Name Facil'Lty IDX(if applicable)
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147 O a Sd � A it fL
Physi,cd Address,City,and Zip _ fL M
_ 00/O ds
County Parcel Identification No.(PIN) 4n, o e V It
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) // 22.C catio
35 g'/ `� 8o6 -36 ' 3F
N W 1 vile av�� i:'':y n'rj lJRat
6.b(are)the well(s): ermaneat or OTemporary Signature ofd6fified Well Contractor Date
B,v signing this form,I herebv cerdJv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *140 1 SA NCAC 02C.0100 or I SA 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:
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-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R) Submit this GW-1 within 30 der of well completion
For multiple wells Gst all depths if different(example-3Qa 200'and,2Qa 100) lays n►p per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfxnter level is above casing;use
11.Borehole diameter. 6" (i,) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constriction method:
Air Drill 24c.For Water Supply and O 1 pen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) coup environmental health d
ry epartment of the county where installed
FOR WATER SUPPLY LLS ONLY:
24d.For Water Wells producfnp over 100,000 GPD:Copy to DWR CCPCUA
Air Permit Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) Method of test: n
13b.Disinfection type: Sterllene Amount: C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018