GW1-2021-03195_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only:
1.Well Contractor Information: ':
Ricky Corriher -
Well Contractor Name FROM TO DESCREMON
� tC1 ft- yv fL
24C4-A iitfctl�,3to!n ion ft. ft.
NC Well Contractor Certification Number IDL u`i�
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DL4METER TtaCYNESS MATERIAI,
ft. ft. in
Company Name
iJ eRaha
2.Well Construction Permit#: S L FROM TO r AIAMETER THICKNESS MA7 ERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) +1 ft 1,10 ft SDR-21 JPVC
3.Well Use(check well use): )6 V ft. &Z ft. S ar in. f kc.-' e w
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑NJdnictpal/Public ft. f, is i
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) (L fL ►a
❑Industrial/Commercial ❑Residential Water Supply(shared)
ObTiation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 22 ft. Bentonite Hale Plug
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation g..... .._._
❑,Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fL ft,
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM TO DESC x color,hardness,soillrock size,eta
O ". YO It ,e w-
4.Date Well(s)Completed: J�-&?/Well ID# 110 IL 90 ft C`
/�fdY ft ft. G
Sa.Well Location: /, / ,�, /-�
'(� LG l�`e'—z/l� 1,2...fti 6 s ft. lG^Pi V ro
Facility/Ow&r Name Facility� pp IC I M ft.5C t 41k,
ft ft.
c
Physic 1 ddresa,City,and Zip fL ft
z
OWN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fiel .c:�J ��}is'su�ffic�ien�t) p `� t/} 22.Ce 'rcatio 1
35e Z'-7- r_e�_L__N 0� � 3` eC/ t f W /
6.Is(are)the wen(s): Wermanent or ❑Temporary SiYhature of C ified well 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 Wo 15A NCAC 02C.0100 or 1 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#11 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 constriction info
construction,only 1 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 wen depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ififi ferent(example-3@200'and 2@1001
0 ) 24a. For An Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (M Formation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: lT Cn 24b.For Injection Wens:Copy toy DWR,Underground Injection Control(NC)
(in.) Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air D rl I I 24c.For Water Supply and Open-Loop Geothermal Return Wens:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co to D
�] Permit Program,161 MSC,Raleigh,NC 27699-1611 Copy CCPGUA
13a.Yield(gpm) � Method of test:Air #C..7t
13b.Disinfection type: Sterilene Amount:
Farm GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018