GW1-2021-02554_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher N
Well Contractor Name 2021 FROM fLST L D s I ON
2464-A SE ,sin it ft.
NC Well Contractor Certification Number ��?1(�r Se 10n -- _.
Frank A. Corriher & Sons Well Drttl��li�, RS � FROM TO DIAMETER THICKNESS MATERIAL
it ft. in.
Company Name /�j
2.Well Construction Permit#: L LJ' V FROM I TO DIAMETER THICXNEss MATERIAL
List all applicable well construction permits(i.e.UIC,Coun(y,State,Variance,etc.) +1 tt 170 fL 6 1/8 in- SDR-21 PVC
3.Well Use(check well use): 7-a fL fL 1°' C ✓
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ ctpal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) tKesidential Water Supply(single) ft fL in
❑industrial/Commercial ❑Residential Water Supply(shared)
Dirrigation. ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . O f` 22 f` Bentonite Hole Plug
❑Monitoring ❑Recovery ft M
Injection Well: % IL
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control ft. fL
❑Geothermal(Closed Loop) ❑Tracer ...
FROM TO DESCRIPTION co hardness,soilfroek Fbm,ett.)
❑Geothermal eating/Cooling Return)n ❑Other(ex lain under#21 Remarks)
qh
4.Date Well(s)Completed: Well ID# ^^77 iL ?X fL rtLy
5a.Well Location: �io�iLs�`
� fL,fie &
Facility/Owner Name Facility ID#(if applicable) M ft
FO G�te6ez /� 61 y e fL IL
�,,,� C fs�c �'j
Physical Address,City,and Zip % fL
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.Certifcation'
6.ls(are)the well(s): W.Irmanent or ❑Temporary Signature of C Date
fiv signing this form,I hereby terry v Mbar the—11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or �/Io 1 SA NCAC 01C.0100 or I SA NCAC 02C.0200 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#21 remarkr 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-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: (ft.)
For multiple wells list all depths if different(example-3()a 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 iDWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Well construction method: Air Drill
(Le 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produc'intr over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
n
13b.Disinfection type: Sterilene Amount: ) !bl (iGt
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018