GW1-2021-00427_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
wall Contractor Nam FROM To DESCRIP770N
2464-A 73' ft q� ft 2
& M
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO nTAMErER MATERIAL
ft ft in.
Company Name � �o /l/J� -
g XWOMM
2.Well Construction Permit#: FROM I To DL4ME1zR 1»ctavEss MAz•ERIAr
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +16) fL b 2 fL 6 1/8 m. SDR-21 PVC
3.Well Use(check well use): 2- ft 4 Yft
Water Supply Well: FROM TO DIANTE7ER SLOTS= THICXNESS MATERW
❑Agricultural ❑�.id
cipaUPublic ft ft. in
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) tt ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METITOD&AMOUNT
Non-Water Supply Well: 0 ft' 22 fL Bentonite IHOJe Plug
❑Monitoring ❑Recovery ft. ft
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation ,...... ...._. _ _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL, EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DES ON Tor hardn iurock size•e�
CO ft a ft. `
4.Date'Wells)Completed:/0./�-o(( Well ED# S fL 6 ft
y1.
ell Location:
�eV gor77 fL fL
Facility/Owns Name Facility ID#(if applicable) fL ft
Rs�e
l I q Co"n4C y M coo zd a w-5 Of fa /, CL fL it I
Ph ' 1 Address Z—� & ft r-
zi -3�'-�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR SECTION
(if well field,one lat/long is sufficient)
35 3 S^ 3 t/ N w 80 ` I t ZZ.Ce cation:
��// V ` �0
6.Is(are)the well(s): Permanent or ❑Temporary Signattma of Miked Well 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: 17Yes or o 1 SA NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this 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 thisform.
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 O'er in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 9 Q5 (ft)
For multiple wells list all depths if different(example-3@100'and 1@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30 (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: 611 (in.) 24b.For Injection Wells:Copy fo DWR,Underground Injection Control(IUC)
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction 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 Producin¢over 100 000 GPD•Copy to DWR,CCPCUA
13a Yield(gpm) � Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: � C
Form GW-1 Notch Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018