GW1-2021-00425_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
FROM 4DE.S.CRnMONWell Conhacwr Name /�O � z2464-A NC Well Contractor Certification Number 7. fL
ftaFrank A. Corriher& Sons Well Drilling, Inc. EOM IMETER TMCiavesS MATERIAL
ft. ft. in.
Company Name f�
2.Well Construction Permit#: / 3 FROM TO DIAMETER TMCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 ft ft- 6 1/8 m. SDR-21 PVC
3.Well Use(check well use): (J`'f `l ft �° lY a V
Water Supply Well: FROM TO DIAMETER SLOT SEM THICKNESS MATERIAL
OAgricultural ee'swential
cipaUPublic ft. ft in.
OGeothermal(Heating/Cooling Supply) Water Supply(single) ft. fL
❑lndustriaUCommercial OResidential Water Supply(shared)
1
Olrri ation ❑Wells>100,000 GPD FROM TO MATERIAL TT!EMPLACEMENT METHOD&AMO[1NT'
Non-Water Supply Well: O ft 22 h Bentonite Hole Plug
❑Monitoring ORecovery ft ft
Injection Well:
it it
OAquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stotmwater Drainage fr. ft
OExperimental Technology OSubsidence Control fL ft
❑Geothermal(Closed Loop) ❑Tracer ORION i
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color a soiliroetrtype.graw erne,etc)
/ ) o ft $V/� f tc_)vl> i
4.Date Well(s)Completed: r0 l r Well ID# �(� ft 170 ft
/� 1►^
5a.Well Location: V It / It S0 V-�' 7t_oC��--
}�fa ft 3vS fQ 13 C t
Fact ty/ atoe (f� / Facility lD#(if applicable) ft ft
/�(�S7l/� nCO /Y1'14 _f✓!Cc/f ft
Physical Address,City,and Zip ft. ft
-Tr -/ /I "
ifya mw
J
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.Cerdfication:
35 0,32/5-6 N 80 G -y9 ' - 3 q ' W
6.b(are)the well(s): l Irmanent or OTemporary S45iture ofC&ffied ell Contractor Date
l;v 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 01C.0100 or 15A NCAC 01C_0200 Well Construction Standards and that a copy
If this is a repay,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 nettled. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
/�n
9.Total well depth below land surface: �t V-5- (ft-) 24.SUBMITTAL INSTRUCTIONS
For multiple wells list all depths;fdifferent(exe;wple-3Qa 200'an 2@1001 Submit this GW-1 within 30 days of well completion per the following:
0'L/10.Static water level below top of casing: p( (ft. 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: 6" (�) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill i
(i.e.auger,rotary,cable,direct push,etc J
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health depathnent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Wager Wells producinelover 100,000 GPD•Copy to DWR,CCPCUA
Air Petmrt Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 3 Method of test:
13b.Disinfection type: Sterilene Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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