GW1-2021-06462_Well Construction - GW1_20211022

X%J N mrX.Ek.wKU u W-1 IFor Internal Use Only:
I.Well Contractor Information:
Ricky Corriher T _
Well Contractor Name �® y FROM TO DESCRIPTION
2464-A
ft
NC Well Contractor Certification Number O ^fit 0f�0 �� 0_ 3�0 it-
Frank A. Corriher& So ls:. �,f?{ Y�llling, Inc. FROM To DIAMETER TMCIMSS MATERL►L
�{ ft ft.
Nam Na � � I1 t^ m
2.Well Construction Permit#: FROM TO MA IpL
DIAMETER THICKNESS TFg
List all applicable well construction permits(i.e.UIC, unty,State,Variance,etc.) t 1 ft �3 fL 6 1 !O SD C11 PVC
3.Well Use(check well use): fL S ft 6 S-/ u G� e
Water Supply Well: - D
❑ cultural FROM To DIAMETER SLOT SITE THICKNESS MATERIAL
� O �cipal/Public fL ft. in.
❑Geothermal(Heating/Cooling Supply) �sidential Water Supply(single)
ft fL in.
❑Industrial/Commercial ❑R idential Water Supply(shared) - -
❑IIIi ation ❑ lls>100,000 GPD FROM TO MATERIAL EMPLACEMNTE METHOD&AMOUNT
Non-Water Supply Well: 0 0 22 fL Beritonite Hole Plug
❑Monitoring ORe covery— fL fL
Injection Well:
OAquifer Recharge ❑ undwater Remediation ft t
❑Aquifer Storage and Recovery ❑S ' •ty Barrier FROM fL -
MATERIAL MPI,ACEM
❑Aquifer Test ❑St Imwater Drainage ft- tt E ENTMETHOD
❑Experimental Technology ❑Su sidence Control ft fL
❑Geothermal(Closed Loop) ❑T
❑Geothermal eating/Cooling Return) OM Ler(explain under#21 Remarks) FROM! TO DESCRUMON color,tuWa soWrock eto)
(j
n 0 ft �/ ft
4.Date Well(s)Completed: 9 3/_Og/ I Veil ID# ft o ft Or L y
5a.Well Location: as'-ft %
l-/,r r:S fo�pAh ft ft
Facility/owner Name Facility ID#(if applicable) ft ft
V I O 1 ft ft
Physi Address,City,and Zip
O 1n�a/iLl
I CP-' Q/ 0
County arcel Identification No.(PIN) Ima
5b.Latitude and longitude in degrees/minutes/s wonds or decimal degrees: �';0''t ,rl`06
(if well field,
one lat/long is sufficient)
35 a 7 7 t f' $� — 3 !/ 22.C cation:
6.1s(are)the well(s): i-rmanent or ❑Te rorary Signahae'of 6ll e Coatractoi 13
Date /
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1 SA NCAC 02C.0100 or ISA N&C 02C.0200 Well Construction Standards and that a copy
If thus is a repair,fiU out known well construction injotart 'on and explain the nature of the of this record has been provided to the we11 own repair under#21 remarla section or on the back of this fo er.
23-Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop GeOtheru al 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 Ovef in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3&00'and 1 aQ100') Submit this GW-1 within 30 days of well completion n p per the following:
10.Static water level below top of casing: d^ ( ) 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: sn (v►) 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 environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d For Water Wells producin¢over 100 000 GPD-Copy to DWR,CCPCUA
13a.Yield(gpm) e+ Method o test•_Air Percent Program,1611 MSC,Ralergh,NC 27699-161 I
13b.Disinfection type: Sterllene Am unt: �
Form GW-1 No Carolina Department of Environmental Quality-Division of Water Resources
Revised 6r6-2018
i