GW1-2021-05903_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) J For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A 1pti1 70 ft fL l:
�► A fL ft
NC Well Contractor Certification Number q. tQ� or9 FROM TO DIAMETER� _ - -ass.. z _ . _ -
Frank A. Corriher & Sons Well Dri l� t gec it ft
THICKNESS MATERIAL
Company Name FROM To DIAMETER
2
2.Well Construction Permit#: THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) + ft 6 1/g in- SDR-21 PVC.
3.Well Use(check well use): ft. fL /Jt- C, 4 v
Water Supply 1 Well: FROM
M TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural eesiaential
crpal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
�t3
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O iL 22 ft Benionite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL. EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer Qlif aitioa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES oN co ba ess soiurock a size ete
n / d fL �t L-) ft V,
4.Date Well(s)Completed: lam / Well ID# ft. .2—iL 5 1144- ql-
5a.Well Location: �G'�i�(/-�RS� 2- f t 02 Y -L /3 0t a re1402-
e#7 fL rL
Facility/Owner Name Facility ID#(if applicabl ft. ft
o P CG-Pt au/ Az-17 U- it. %
Physical Ad ss,City, ip ft. ft
Cie GlD'6u
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif cation-
35e ,91 " N80 Z/Qi— ��� W - �/
6.Is(are)the well(s): Wemanent or ❑Temporary Signature of CTAffied Well Contractor Date
Ikv 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 ko 15A NCAC 02C.0100 or 1 SA NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis 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: 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 if different(example-3Q200'and 1@100)
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"+"
6" 24b.For Injection Wells: Copy 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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
L
ATER SUPPLY WEE LS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
ld(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
infectiontype: Sterilene Amount: CQ
Form GW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-2018