GW1-2021-02544_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -Well Contractor Name FROM TO DESCRIPTION
2464-A ft ft
% M I
NC Well Contractor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO D T TMCKNMs MATERIAL
ft. M in.
Company Name _
2.Well Construction Permit#:y —Q001-63- 1oll- FROM TO DIAMETER TMCICMS I MATERIAL,
List all applicable well construction permits(z.e.UIC,County,State,Variance,etc.) +1 ft a fL 6 1/g iL SDR-21 JPVC
3.Well Use(check well use): fL L it in.
Water Supply Well: FROM _ To DIAMETER sf DT sLZE THICKNM MATERIAL,
❑Agricultural ❑residential
ctpaVPublic fL ft in
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
121ni ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METLLOD&AMo[nvT
Non-Water Supply Well: 0 ft 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other( FROM TO DESCREM Ncolor,hardness,soil/roek lain under#21 Remarks) size,etc-)
rt m
4.Date Well(s)Completed: /r _ � Well ID# ft L ft
Sa Well Location:
Ir
ft
6r e�oane y ScAIn rat fL ft
Facility/Owr Name Facility ID#(if applicable) / fL M
ft fL02
Physical Address,City,and Zip ft. ft
/ �il�D �a
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
W3 Z` /�" $Q 0_`j� 3s W
•( zz.certircaaon:
`/ Nzo
6.Is(are)the well(s): Permanent or ❑Temporary Date
Signature of ed ell Contractor
By signing this form,I hereby certify that the xell(s)was(were)constructed in accordance with-
7.Is this a repair to an existing well. ❑Yes or 14/1 15A 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#11 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 I 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:
For multiple wells list all depths if d fferent(example-3©200'and 2®101Y) ( ) 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(RjC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Drill
(ie.auger,rotary,cable,direct push,etc.)
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: Copy WR,CCPCUA
24d For Water WellsFor Water Wells produ�over 10U 000 GPD100 000 GPD- Co to D
13a.Yield(gpm) Method of test:
Air Permit Program 1611 MSC,Raleigh,NC 27699- 6611
13b.Disinfection type: Sterilene Amount:�C
I
Form GrW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6.2018