GW1--03326_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD (GW-I) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher _
Well Contractor Name FROM TO DESCRIPTION
2464-A
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. _
FROM TO DIAMF,'TER .THICKNESS
ft it in Company Name
2.Well Construction Permit#' p` FROM TO n THICIMSs MATERUL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) +1 ft 7 ft 6 118 `n SDR-21 PVC.
3:Well Use(check well use): rt ft c
Water Supply Well:
❑Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑ cipa]/Public ft it iIL
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft ft in.
❑lndusttiaVCOmmercial ❑Residential Water Supply(shared) -
OIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
b Injection Well:
❑A uifer Recharge ❑Groundwater Remediatiori t it
r^ ❑Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIpI,
EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
V ❑Experimental Technology ❑Subsidence Control it ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return)) 0Other(explain"under#21 Remarks) FROM TO DES ON color hardn soivrock sue etc,
4.Date Well(s)Completed- Well ID# 0 M it C
5a Well Location: ft O ft
.W/ a 1�/✓r 1 611,� 0 ft ft
Facility/Owner Name Facility ID#(if applicable) f it
G� A `t
r it it MAY 2 Z
Ph * 1 Address,City,and Zip ft ft
v r'd
County Paicel Identification No.(PIN) v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
t 9 , // 22.Certificatio .
6.Is(are)the well(s): Mermanent or ❑Temporary Si o rtified Well Contractor Date
9 .
i y 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 6<0 . . 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a Copt•Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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 I GW-1 is needed Indicate TOTAL NUMBER of wells ( 'See Over'in Rema&s Box).You may also attach additional pages if necessary,
drilled:
r 24.SUBMrrrAL INSTRUCTIONS
9.Total well depth below land surface: L/J (ft.)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100� Submit this GW-1 within 30 days of well completion per.the following: .
10.Static water level below top of casing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
(i•e•auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells-Copy to the
county environmentai health department of the county where installed
FOR WATER SUPPLY WE LLS ONLY: -
/�/ 24d-For Water Wells producing over 100 000 GPD-Copy to DWR,CCPCUA
13a.Yield(gP m) Method of test:AI r Permit Program,1611 MSC,Rale1 NC 27699-1611
13b.Disinfection type: Sterilene Amount:_
!. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 6-6-2018