GW1-2021-02531_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Ricky Corriher 5
Well Contractor Name FROM TO DESCRIPTION
2464-A " r
ft ft !
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO D T TMOMM MATERL►I.
ft ft ln,
Company Name
2.Well Construction Permit#: V FROM TO DIAMETER TMICENESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) +1 ft {t 6 1/8 � SDR-21 PVC
3.Well Use(check well use): l ft 3 ft
Water Supply Well: FROM ._, TO DIAMETER D sLOT SIZE THICIavFss MATERIAL.
❑Agricultural ❑ unicipaUPublic ft ft in
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
DIrrigation ❑Wells>100;000 GPD FROM TO MATERIAL EMPLACEMENT METMOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery fr. fL
Injection Well: ft . ft
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETMOD
❑Aquifer Test ❑Stormwater Drainage ft {t
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal FROM TO DESCRIPTION color,hardn soWrock size,ere)
(Heating/Cooling Re�t/urn) ❑Other(explain under#21 Remarks) d ft- ,3d it
4.Date Well(s)Completed:'-rfr/- >/ Well ID# l 0 ft 3 tt C
fL
Sa Well Lotio fieS(. /J {t rt t
Facility/Owner Name FF� ID#(if applica e) ft ft
Physical dress,City,and Zip ft ft
_f�o
County Parcel Identification No.(PIN) p�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient)
350 l ^ t 1 N 80 -` p 0 I _ �� /I �22.Certifcalion, \E
6.Is(are)the well(s): W.r•manent or ❑Temporary Signature of ed ell 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: ❑Yes or kNo ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fell 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 needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ! �� (ft)
For muUrple wells list all depths ifeli ffete an 2Q100 Submit this GW-1 within 30 days
nt(example-3@2uei" d � of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (R-) Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use
g 8h,
11.Borehole diameter: 61@ (�) 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(IUC)
Program, ,Raleigh,
1636 MSC, 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 SUPPLYIELLS ONLY: 24d.For Water Wells prod ucin8 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) 0 Method of test•
Air Permit Program 1611 MSC,Raleigh NC 27699-1611
13b.Disinfection type: Ste ri I e n e Amount: C BPS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018