GW1-2021-02522_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher �- --,
Well Contractor Name FROM TO DESCRIPTION
2464-A 0 `t 1240`t 49
ft ft
NC Well Contractor Certification Number it as e O
Frank A. Corriher& Sons Well Drilling, Inc. FROM I To De ft ETER in. THICKNESS MATERIAL
Company Name ,� I
2.Well Construction Permit#: % 1 r h FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UlC, ntv,State,Variance,etc.) t tt Z,ft 6 1/8 in SDR-21 PVC
3.Well Use(check well use): tt t - 4
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) _aidential Water Supply(single) ft ft in.
❑In trial/Commercial ❑Residential Water Supply(shared) CsTtU
ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 0
.°_- .. - $ilio
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,somrock ; etc)
tV ft t) ft
4.Date Wells)Completed: Well ID# ft Z eft �C
5a.Well Location: ` ?v ft /C�U it So
Facility/Owner Name Facility ID#(if applicable) ft ft
�� �a�°S ft tt
Physical A dress,City,and Zip o— ft ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f P1$OI� 3tt0i1 ''
(ifwell field,one lattlong is sufficient)N �O O ���` �`� 22.Cetirk,.'a/tion:35� `/'�'19� W
6.Is(areXthe well(s): Permanent or ❑Temporary Signature of Mitfied Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or VO 1 SA NCAC 01C.0100 or!SA NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis 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 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-I 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: h /C ft-)
For multiple wells list all depths ifdii ferent(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: (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" (in,) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC12 7699-1 63 6
12.Well construction method:Air Drill
, , , . 24c.For Water
(i.e.auger,rotary,cable direct push etc) Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producine over 100 000 GPD• Co Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount: 2 Cali
ali
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018