GW1-2021-02563_Well Construction - GW1_20210901

WELL I:UMTKUC•1•lON RECORD (GW-11 � For Internal Use Only:
1.Well Contractor Information: ID1
Ricky Corriher �
Well Contractor Name P FROM TO DESCREMON
S o ft.-
2464-A
ti.)1�11 fL ft
NC Well Contractor Certification Number
1eta:, ��IJL'i10i1
Frank A. Corriher & Sons Well Dr
il Ig Inc. oM To DIAMETER THICKNFSs MATERIAL
�j ft it ! in.
Company Name ✓��a �
2.Well Construction Permit#: FROM TO DIAMETER I THMKNESS MATERIAL
List all applicable well construction permits(i.e.U!G Counov State,Variance,etc.) +1 fL fL 6 1/8 In SDR-21 PVC
3.Well Use(check well use): fL ft
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural �❑ ipal/Public ft fL in.
El Geothermal(Heating/Cooling Supply) ffiResidential Water Supply(single) fL fL in.
❑IndustriaUCornmercial ❑Residential Water Supply(shared) -
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery fL ft
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control % M
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESC ON color, soilfrock size,etc.)
fL fL )—
4.Date Well(s)Completed:S'�1_621 Well ID# r,�v ft r6_3 fz -5 k-
5a.Well Location: Do-aw/40// fL fL ICI,e— G y
fL fL
Facility/Ownei Name Facility ID#(if applicable) ft ft
3 fL fL
Physical Address,,City,and ip ft ft
-4 red
County Parcel Identification No.(PIN) IJ
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --
(if well field,one latnong is sufficient) 22.Ce cation
35o g/3�1i N 80°_�Q '/ '/ w
6.Is(are)the well(s): kr/ermanent or ❑Temporary sigra-V=of C zti ed r.0 Contractor Date
By signing this form,1 hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or V. 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthis is a repair fill out known well construction information and explain the nature of the ofthis record has been provided to the well 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-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
P (ft)
ft 24.SUBMITTA INSTRUCTIONS
9.Total well depth below land surface: L
(
For multiple wells list all depths if different(example-3@200'and 00) ) Submit this GW-1 within 30 days of well completion per the following:
Z4a. For All Wells: Original form to Division of Water Resources DWR
10.Static water level below top of casing: (R,) gtaal ( ),
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)
Air Drill Program, 1636 MSC,Raleigh,N027699-1636
12.Well construction method:(i.e.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: 24d.For Water Wells yroducin¢over 100 000 GPD•Copy to D
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611 CCPCUA
13a.Yield(gpm) 3 Method of test /+
13b.Disinfection type: Sterilene Amount
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018