GW1-2021-06463_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD GW-1 � For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher ��
Well Contractor Name FROM t TO DESCRIPTION
2464-A ��� `� e \0 "� fL �asft. G 4
NC Well Contractor Certification Number �r�`�9r'���
Frank A. Corriher & Sons` l 61g, Inc. FROM I TO DIAMETERS Tmcla ssI MATERIAL
M fL
Company Name -
2.Well Construction Permit#: (/ FROM TO DIAMETER TffiCIQYEgS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft X& ft 6 1/g in- SD R-21 PVC
3.Well Use(check well use): ! fL l [t n.
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural Zidential
ft ft in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft fL in.
❑lndustrial/Commemial ❑Residential Water Supply(shared)
❑hsi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 Bentonite Hole Plug
❑Monitoring ❑Recovery fL ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation WWROW__.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM .. TO Dfn7ERInL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal FROM TO DES ON color,hardnes s,so iY a ,et(Fieating/Cooling Return) ❑Other(explain under#21 Remarks) fL tL iuc)
rf t
4.Date We Completed:©4'r�/l Well ID# fL 0 fL Z /
5a.Well Locati n: ft o [t
l 6 ft.
L2� to
`-� Facility/Owner Name Facility ID#(if applicable) 1L ft
fL fL
Physical dress,City,and Zip M fL
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latQong is sufficient) 22.Ce cation-
35 �' N 80 l J
f� w
O -
6.Is(are)the well(s): ermanent or ❑Temporary Sig,rature of ed ell Contractor Date
fiy signing this form,I herekv certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V, 15A NCAC 02C.0100 or ISA NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis is a repair•fill out brown 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 I GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
P 5- fL 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ifdifjerent(example-3©200'and 2@100� ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: t� (ft.) 24a• For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use-+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (;n,) 24b.For Iniection Wells:Copy to DWF Underground Injection Control(IUC)
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
(i.Well consyrcable, method: 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
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD• Co to D
13a Yield(gpm) ,-n Method of test
Air Permit�frm,1611 MSC,Raleigh,NC 27699-1611 py �✓R,CCPCUA
% G 5
13b.Disinfection type: Sterilene Amount:_,�{
i
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised G 6-2018