GW1-2021-06638_Well Construction - GW1_20211007

yrrI JL,<,V1,401KUl:11un KL+uukw,((;W-1) For Internal Use Only:
1.Well Contractor Information: '
Ricky Corriher -
��� ft t C1tLYIION
Well Contractor Name � FROM TO DES
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2464-A �� `� ft. ft.
NC Well Contractor C lification Number 50 110 i -
1r1fo g4?, ;MTERFrank A. Corriher& Sons Well Drilling,Dlnc. TO DIAMETER T1ncxNEss Company Name � � m.
2.Well Construction Permit#: FROMTO IAMTER TMCIQVESs WLList all applicable well construction permits(ie.UIC,Coursty,State,Variance,etc.) t1 1�� SDR-21
3.Well Use(check well use): Y ft C� ft. ,�' 1II D'd
Water Supply Well: FROM TO DIAMETER stoT SIZE T111CXNESS I MATERIAL
OAgricultural ❑tesidential
ctpal/Public ft ft in
OG-thermal(Heating/Cooling Supply) Water Supply(staFle) fL ft in.
oindushial/Commercial OResidentiai Water Supply(shared) -
ObTigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 22 fL Benionite Hole Plug
❑Monitoring (]Recovery ft ft
Injection Well: ft fL
OAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier titoM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage ft fL
OExperimental Technology OSubsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return) OOther(explain under#21 Remarks) FROM fL TO DESCRIPTION color,Mran soilnock tym mmin size,etc
4.Date Well(s)Completed: U 30-1 wen um S— ft fL
5a.Well Location'
e
F�1, #e#)e Sc--1es tt IL,
Faciliitf
ty�/owwq'Name y ,p Facility ID##(if applicable) l fL fL
1Vd(i(/� r /r ' 4dl d��_I/� 11tl�Ir+4Skt! ft. fL
Physrca Address, ity,and Zip ft ft
f
.fir.e Ll 65-.33-84J 8
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) q 22.Ce ' cation: l
359� `� � n tt N �� a ' �Qr� t '' W �I
oC ff 4-
6.h(are)the well(s): l*'l'errnanent or ❑Temporary Signature of ed ell Contractor, Date
�/ By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LRNo 15A NCAC 02C.0100 or l SA NC,4C 02C.0200 Well Construction Standards and that a copy
ff this is a repair,fill out brown 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 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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.sUBmn-fAL INSTRUCTIONS
9.Total well depth below land surface: 11 (ft) Submit this GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2Q100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (fL)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water level is above casing,use
11.Borehole diameter: 6" ( ,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12 Well construction method,Air Drill 24c.For Water Supply and Opel-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 producint over 100,000 GPD:Cop
y to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type:Sterilene Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019