GW1-2021-06609_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corrihe'r
Well Contractor Name FROM TO DESCRIP11ON
166L 1,2S 3 p
2464-A ft ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. nM TO DIAMETER THICKNESS MATERIAL
rt n
Company Name
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) +1 fit 9S ft 6 1/8 1D SDR-21 PVC
3.Well Use(check well use): it �7 it GA- I /*-� a jJ
Water Supply Well: FROM TO DIAMETER SLOT SIZEa THICKNEss MATERIAL
❑Agricultural ❑tsidential
crpaUPublic ft. M in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Q
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 22 tt Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
it. fit
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer j1 atta a t► - sees
FROM TO DESCRIPTION color,hardness,soillrock size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft rt
4.Date Well(s)Completed: l / Well ID# �Q ft ft. Ct� &X)L
5a.Well Location: ft vs—ft ✓ (�� 4-
rt ft.
Facility/Owner Name > /� Facility ID#(if appl' ble) It. ft.a 3 , �G/� /TDGJ� �i� rt ft.
Physical Address,City,and Zip fit fit
5�z� rr .S a.
County Parcel Identification No.(PIN) DV'JR
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
35 N 80 3� W
6.Is(are)the well(s): 06manent or ❑Temporary Signature of CTrkfied ell Contractor Date
By 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 0 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: fI U 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / 7 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100)
0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use-+"
11.Borehole diameter: 6" (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
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
(i.e.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: Copy to DWR CCPCUA
13a.Yield Wm) �/
/} Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount: CQ S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018