GW1-2021-06608_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1). For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher � -
� i� FROM TO DESCRIPTION
Well Contractor Name �� o ''
2464-A �,O,e=s\�9 fti tt
NC Well Contractor Certification Number O C,3,0G\(��
Frank A. Corriher & So\19t3 IV4� Grilling, Inc. oM D1wHtrtrru THICKNESs MATERIAL
tt. ft in
Company Name -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �—
1+ ft `� tt 61/8' In SDR-21 PVC
List all applicable will construction permits(.e.UIC,County,State,Variance,etc.) !�
3.Well Use(check well use): 3k fL 3 ft
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipah?ublic fL ft
OGeothmmal(Heating/Cooling Supply) Niesidential Water Supply(single) tt_ fL in
❑Industrial/Commercial ❑Residential Water Supply(shared) _
01trigation ❑Wells>100,000 GPD I FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 B- Bent6nite Hole Plug
❑Monitoring ❑Recovery % ft
Injection Well: tt. ft.
❑Aquifer Recharge OGroundwater Remediation _
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology 0Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION color,hardness,soiVroelt sae,eta
❑Geothermal(Heating/CoolinngJ Return) ❑Other(explain under#21 Remarks) tr. it 1 U'
4.Date Well(s)Completed: l�I Well ID# fL 3 n" Ira L o Cl�
3 t. t i �-
Sa.Well Location:
t ft. fL
Facilityfivin am
ID# if likable ft. tt
Facility/owner/Ngame�j (�� C aPP )
-3 8 V L/ �!�� / 1G� ft. ft
Lt��C�/ ft. it.
Physical Ad s,City,and Zip
Count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) (� 22.Ce cation:
35'*g g 3 t t N $0' 1� W
Signat of ed ell Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary ure '
By signing this form,l hereby certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or I SA NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a copy
lfthis 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 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 ifdi,(jerent(example-3Q200'and 2@1001
/� 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: '3 11 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
6" 24b.For Injection Wells:Cagy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-) 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
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
L13aYield
TER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
(gpm) Method oftest:
AirPermit Program,1611 MSC,Raleigh,NC 27699-1611
nfectiontype: Sterilene Amount. Cp S
k
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018