GW1--03143_Well Construction - GW1_20230505

WELL.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher FROM TO DESCRIPTION
Well Contractor Name 3 20 (' fL 3.OL
2464-A- `��'C� fL ft
NC Well Co=actor Certification Number
Frank A. Corriher 81 Sons Well Drilling, Inc. FROM TO DIAMEI7R imlicTavEss MATERIAL
ft ft is
Company Name FROM TO —
2.Well Construction Permit#:-Gym 7 D,a,�rxR TinciavEss MATERIAL
all applicable well construction permits(.a UIC,County,star t 1/Cii�c�t„e . .a "p d a+�'"�, it it 6 1/8 1° SDR-21 PVC
,List
Well Use(check well use): _ S '12
Water Supply Well: � FROM TO DIAMETER SLOTSIZE THICffir$SS MATERIAL
❑Agricultural ❑Itl+fniCipailic a ^r.� ,�'•, 1.fii ft ft in.
❑Geothermal(Heatingicooling Supply) Residential Water Stl'plilW11914 ft ft in
❑lndtuttial/Commercial ❑Residential Water Supply(shared)
❑hri 'pn ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 122 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation __._
Now
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test - ❑Stormwatcr Drainage ft ft
❑Experimental Technology ❑Subsidence Control it = ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM fL I To DESCRIPTION aoto,badness soiYroet sma
eta)
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4.Date Well(s)Completed: U ID# 0 () C
Sa W ll Lo lion: a to ft 7 it J nL f L
0 S lti� 17!/t �� C -V f L G•
Facility/Owner Name Facility ID#(ifapplicable) ft. ft Gym
ft ft
Physical Address,City,and Zip
R 0 t✓ C'/I
County Parcel Identification No_(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.C ation. /
3 N / W
6.Is(are)the well(s): --anent or ❑Temporary Signature of Ce ' ell Contractor Date
By signing thisfornt,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or i o I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Wen Construction Standards and that a copy
If this is a repair,filf out known weU construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 rmarks section or on the back of thisform.
73.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 ( '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) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 a200'''andL2�@I00O
: �/� v ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing
10.Static
level is above casing use op Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If 11.Borehole diameter 6" (in) 24b.For Injection Wells: Copy to DWF-,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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:Co D
3 O Method of test.Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy to �CCPCUA
13a.Yield(gpm)
13b.Disinfection type: Sterilene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resburces Revised 6-6-2018