GW1-2021-00439_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher - -
Well Contractor Natne FROM TO DESCRIPTION? ft. � ft.2464-A ft. fL
NC Well Contractor Certification Number --
00-0
Frank A. Cornher& Sons Well Drilling, Inc. FROM TO DIAMETER THICtavess MATERIAL
tt ft. fn
Company Name O `
2.Well Construction Permit#: /J �/f �!l FROM TO DL4METER THICKNESS �ATERULList all applicable well construction permits(Le.UIC,County,State,Variance,etc.) +1 ft t/ ft 6 1�g 'n SDR-21
3.Well Use(check well use): Y fL ` fL v
1.� �.
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑ crpal/Public ft. ft UL
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt 22 Bentonite Hole Plug
❑Monitoring ❑Recovery ft. fL
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
FROM TO DES ON color,hardness,so ' size,etc)
d
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /tt � fL db k9v✓ ri t
ct-
4.Date Well(s)Completed: Well ID# a tt Y6 ft. �.
Sa.Well Location: ,C �7 Z fL w O
fL ft.
Facility/Owner Name /� Facility ID#(if applicable) ft. ft.
1
RO C .Q tL fL
/� fL {L
Pby5� 2021
4i OLA l -T t�
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.Certifcatioa:
35 '1 0/ 4210 N 80 - d � 7 W
6.Is(are)the well(s): OPermanent or ❑Temporary Sigoanne of ed ell Contractor Date
By signing this form,I hereby certify that the we (s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out brown 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: 3 (ft.) Submit this GW-1 within 30 da s of well completion r the following:For multiple wells Ust all depths if different(example-3(a)20� 2(Qa 1001 y P per wing:
24a. For All Wells: Original Iform to Division of Water Resources (DWR),
fw Static water level below top of casing: (ft) hnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijwtzter level is above casing,use"+"
11.Borehole diameter:
6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24c.For Water Supply and Op en-Loop Geothermal Return Wells:Copy to the
(Le.sager,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,'00 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: 3 / �.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018