GW1-2021-06607_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: }
1.Well Contractor Information: '��Nj
Ricky Corriher '%g" N
FROM TO DESCRIPTION
Well Contractor Name
2464-A
OBa$
fL ft-
NC Well Contractor Certification Number o^v�1�
Frank A. Con iher & Sons Well0fi irlg,NW�. °M DU METER. T� MATERIAL
ft fL in.
Company Name \�}
2.Well Construction Permit#: r rn ✓ FROM TO DIAMETER rMCKNESS MATERIAL.
List aU applicable well construction permrts(ce.fl .Counov State,Variance,etc.) +1 iL �f 1 fL6 1/8 in' SDR-221i PVC
fL
3.Well Use(check well use): I Y3 !D a G
Water Supply Well: FROM I TO DLAMETER SLAT SIZE TIEICKfUM MATERIAL
❑Auu ❑yctpal/Public ft ft
❑Geothermal(Heating/Cooling Supply) �Resideatial Water Supply(single) f. fL
❑laclustrial/Cotnmercial ❑Residential Water Supply(shared)
❑ ❑Wells>100,000 GPD FROM TO MAT fL
EtfPIACEMENT MrMOD&AMOUNT
Non-Water Supply Well: 0 ft 22 Bentonite Hole Plug
0monitoring ❑Recovery ft. fL
Injection Well: ft. fL
OAquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATEIMAL EMPLACEMENT MET'aoD
❑Aquifer Test
❑StormwaterDrainage ft. ft.
7
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION(color, millroek type, sme,etc)
OGeothermal(Heating/Cooliinng�Return)etu2 ❑Other(explain under#21 Remarks) n l , A _
4.DateWells)Completed: / l✓ "` Well ID# fL
�'3 ft �`/�J ��✓t C,, G- 1(—
5 ell Location: ft. v_ ft 6t e ,) a_q L
�y�a m ;�P✓�l FIS O����i0'Pl/�I�IS 6 ft it
tf licable % fL
Facility/Owner Name Facility M#(• aPp U )
0 Alner C,5pl'W M M
Physical City,and Zip
C'7c,'T a S
count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) O z � `// 22.C ' cation:
N O
35",; 3 �� /!� W
Signanne of
6.1s(are)the weli(s): ermanent or ❑Temporary ed ell Contractoi Dare
� By signing disform,I hereGv ce►afv that the—U(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 1 SA NCAC 02C.0100 or 1 SA NCAC 01C.0200 Weft Construction Standards and that a copy
If this is a repair fill out known weU 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having true same
( See Ovet in Remarks Box).-you may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: n / / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aC `"7 (fL) 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 1 @100)
n 24a. For All Wells: Original Ifotm to Division of Water Resources (DWR),
10.Static water level below top of casing: d� (B) Information Processing Unit,1617 MSC,Raleigh NC 27699-1617
if water level is above casing,use"+"
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
1L Borehole diameter:6 0 -) Program,1636 MSC,Raleigh,NC 27699-'1636
12.Well construction method:Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,daeet push,etc.) county environmental health department of the county where installed
L13a.Yield
TER SUPPLY WELLS ONLY: 24d.For Water Wells producinv over 100,000 GPD:Copy to DWR,CCPCUA
(gpm) Method of test:AIrPeanut Program,1611 MSC,RaleighNC 27699-1611
fectiontype: Sterilene Amount: l `Q
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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