GW1-2021-02609_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name ✓ ft Q Q
2464-A ft ft
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. it TO it in. 'ffi "I"'�
Company Name e
2.Well Construction /Permit#: Q V 1 J"4 OL 1 p FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction potni (I.e.b7C,Co ,State,Partance,etc.) +1 it q ft 6 1/8j t- SDR-21 PVC
3.Well Use(check well use): 7 it G f )
Water Supply Well: FROM To DIAMETER SLOT SUE. THICKNESS MATERIAL
t ❑Agricultural ❑MunicipaUPublic ft ft in.
-]Geothermal(Heating/Cooling Supply) w.residential Water Supply(single) ft ft in.
1ndustria0VCommercial ❑Residential Water Supply(shared)
Iai on ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it 22 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 tt it
❑Experimental Technology ❑Subsidence Control It ft
❑Geothermal(Closed Loop) oTracer
FROM TO DESCRIPTI N color,hardom soWroek rive,9min Sim,etr-
❑Geothermal(Heatin Cooling Return) ❑Other explain under#21 Remarks L0 Y o % w-
4.Date Well(s)Completed: Well ID# %V 1_d 5 /� _ Q
Sa.WellLocatio S-U ft CI 7 it S� l�k
Lv it (� n �2 4- ..n�
Facility/Ow r Name Facility ID#(if applicable) . ?j(� ft s�s tL L`e G
1 +- C44 ert ft
Physical Address,City,and Zip ft ft.
dwc
Count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Ce cation:
35° S' N 8010--30
Si goat of edell Contractor Date
6.Is(are)the well(s): el manent or ❑Temporary tne
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 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 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-1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 � (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3©200'and IQ1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �O (B•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use +"
6° 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in-) Program,1636 MSC,Raleigh,INC 27699-1636
12.Well construction method:Air Drill 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 rodneu-m over 100,000 GPD:_Copy to DWR CCPCUA
Air Pelmrt Program 1611 MSC,RaleI� ��9{)�11��
13a Yield(gpm) 1 go Method of test �/ .
13b.Disinfection type: Sterilene Amount: SCa�p�
� AU6X52021
Form GW-I North Carolina Department Of Environmental Quality-Division of Water antes processing Unit Revised 6 6 2018
Infrrrlatlon
I DWR Section
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