GW1-2021-02330_Well Construction - GW1_20210722

For Internal Use Only: -
1.Well Contractor Information:
Ricky Corriher
Well Contractor Nam fL FROM TO DESCRII'TrON
2464-A ' Cl
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DlaMe M TMt:XNM MATERIAL
ft. ft. is
Company Name -
2.Well Construction Permit#: FROM TO DIAMETER THICIMss MATERIAL
List all applicable well construction permits(1 e.UIC,County,State,Valiance,etc) t ft. /� in' SDR-21 PVC
3.Well Use(check well use): ft 1205VKft. G i° c
Water Supply Well: Ffi0M TO DIAMETER SLOTSIZE THICKNESS MATERIAL
OAgricultural ❑Municipal/Public ft. ft. in.
OGeothernial(Heating/Cooling Supply) -Residential Water Supply(single) ft. ft. in.
OludustriaUCommemial OResidential Water Supply(shared)
on OWells>100,000 GPD FROM TO MATE RIAi EMPLACE IENTMETHOD 3r AMOUNT
Non-Water Supply Well: 0 f° 22 ft- Bentonite Hole Plug
OMonitoring ❑Recovery ft ft.
Injection Well: ft. ft
OAquifer Recharge OGroundwater Remediation _
[]Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft ft
OExperimentai Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed loop) oTracer
OGewthermal eating/Coolin Return) OOther(explain under#21 Remarks) FROM TO DEES3R20,N 00104 tuuda wnrrock The,etc.
f ft tt. 5-0 ft- /�E? tr
4.Date Well(s)Completed:,%'J� Well ID# o It Y' L,A-
5a.Well Location: ft ft S rL
f9 G 1 L e-
Facility/ r Name Facility ID#(if applicab ft
OWcis It f4
Physical Address,City,and Zip
ft. M
ah/.r ru
County Parcel Identification No.(FIN) n
it
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ri�vr[ ,atlon Processing
(if well field,one lattlong is sufficient)
1/ 22.Ce c,�tia
35P �,I d N 84 �- w 1
6.b(are)the well(s): 01 rmanent or OTemporary Signature of Cerfifie Date
F
B,v signing this form,I hereby certifv that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or 6 o 15A NCAC 01C.0100 or 15A NC4C 02C.0200 WeU Construction Standmnds and dhat a wp.v
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 weU 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-i is needed. Indicate TOTAL NUMBER of.wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: �j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 (ft}
For muh k w�eUs list all depths if different(example-3©200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
l� (ft.) 24a. For All Wells:Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit,1617!MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+
6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (m•) 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 pro ducin rover 100,000 R GPD:Copy to DW CCPCUA
13a.Yield(gpm) Method of test:Ai r Permit Program 1611 MSC,Raleigh,'NC 27699-1611
13b.Disinfection type: Sterilene Amount: G G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018