GW1-2022-10683_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM
TO DESCRIPTION
Well Contractor Name /y,It ft t�a ft '3
2464-A ft ft
NC Well Contractor Certification Number 5�0> R�.CAST�G'�a`fo�ui,case, w",ells�(J.
Frank A. Corriher& Sons Well Drilling, Inc. EOM ft. ft. in.TO DIAMETER THICKNESS I MATERIAL
Company Name 2.Well Construction Permit#: 3 7jj 1JI!1iERCA$IiCb -, Iii eoh os.-
( 3-3 3 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft L,0 ft 6 ��8 in. SDR_21 PVC
3.Well Use(check well use): 6- () ft O 2 ft- in• )k Cx cz
0 SCRER ..._.gyp
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural UPublic tt ft. in.
❑ ;7e.sidentialGeothermal(Heating/Cooling Supply) a Water Supply(single) tt ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 777
❑hri ation ❑Wells>100,000GPD L EMPLACEMENT METHOD&Non-Water Supply Well: te Hole Plug
❑Monitoring ❑Recovery Injection Well:
❑Aquifer Recharge El Groundwater Remediation 13
PFROM
❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) To DESCRIPTION eotor,Haan soillrock e, size ere— 1�r t,�v+�4.Date Well(s)Completed: Well ID# &2— ft0 I`DL•-m-Sa. ellL cation: 3'0 t -
ft.
ft.
Facility/O3m Name ility ID#(if aglicabl`� ft ft
��a O" r✓ � DEC
dc
Z - ft rt v c�
Phys• I Address,City,and Zip @. tt
�0 OS� z1�`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) t/ 22.Zei:atio
35 ' J/ " N 8 �-3� � f
6.Is(are)the well(s): ermanent or ❑Tempor ry SigMure of C ed ell Contractor Date
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 1 SA 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 a.:d ezplain 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 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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths jdii ferent(example-3(a)200'and 2@100)
r 24a. For All Wells: Originals form to Division of Water Resources (DWR),
10.Static water level below top of casing: J —(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use•'+"
j .
6-1 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-)
Program,1636 MSC,Raleigh,NC'27699-1636
12.Well construction method:Ai r D ri 11 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.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 27699-1611
13a.Yield(gpm) Method of test: /l
13b.Disinfection type:.Sterilene Amount: 1- 0(3
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018