GW1-2021-06166_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -FROM TO DESCRIPTION
- -
Well Contractor Name
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2464-A ��L
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NC Well Contractor Certification Number - --
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER THICKNESS MATERIAL
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Company Name /�J
2.Well Construction Permit#: , FROM TO DIAMETER THICKNESS3� MATERIAL
List all applicable well construction permits(i.e. /G County,State, Variance,etc.) +1 fL t4/ fL 6 1/8 in' SDR-21 PVC.
3.Well Use(check well use): L ( rt ft
Water Supply Well: FROM TO DIAMETER SL.OTSIZE THICKNESS MATERIAL
❑Agricultural crpa]/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) LAmidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
)�OWE so MEN=
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL 122 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: tL fL
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage f fL
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer UD
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DEs TIN color .rdness utrock ' size,eta
ft. I o2 rL lr
4.Date Well(s)Completed: v O L / Well ID# l ft 3 rt 5 Q
5a.Well Location: '73 fL t ft e
-j- '3 fL ft6def-<6>4S rGn
Facility/Owner ame Facility ID#(if applicabl fL ft.
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C/ a/ ? / fL ft
Pbysic ddress,City,and Zip %� ft ft
County Parcel Identification No.(PIN) Into,rn3�ep�?rnressing Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: WR Section
(if well field,one lat/long is sufficient) 22.Certif cation-
35 W
6.Is(are)the well(s): rlPermanent or ❑Temporary Signature of e ' ed 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 Vo 15A NCAC 02C.0100 or 1 SA NCAC 02C.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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
filled' 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 iifdiiferent(example-3®200'and 2@1001
/f (fL) 24a. For All Wells: Original!form to Division of Water Resources (DWR),
If water level is above coring,use
f Static water level below top of casing: v Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter" 611 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene ,mount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018