GW1-2021-06673_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) � For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher 0, � - -
Well Contractor Name FRO 1O DESCRIPTION
ft.
2464-A r`
NC Well Contractor Certification NumberPI
t�O Ory ��;0 ft ft
Frank A. Corriher& Sons Well Drillod, Ind` EOM To DIAMETER THICIavEss DiwrERIAL
M ft is
Company Name --
2.Well Construction Permit#:I r r) a (A4 I O FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C, unto,State,Variance,etc.) +/1 ft ` ' ft 6 1/g fa $DR-21 PVC.
3.Well Use(check well use): (!�!� tt Q 2 ft f Iq
e
Water Supply Well: FRoM TO DIAMETER SLOTSUZ THICKNESS MATERIAL,
❑Agricultural ❑Municipal(Public ft ft in.
❑Geothermal(Heating/Cooling Supply) CIResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) WNW
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Well: 0 it 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft tt
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer 4' mt
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES O color Aatdn soilfrockrfm grain size,etc-)
ft u/ ft
4.Date Well(s)Completed: ` -( o�( Well ID# Q % L cg ft '-q yf 11 JL
5a.Well Location: 90 ft. AP 2—
rI 1l Q, 1 o At- &s ft
Facility/ r Name Facility ID#(if applicable) ft ft
11S-S La4,t`.�� P ck,Aa Pfr"'&-e it ft
Physical Address,City,and Zip ft ft
K6 tVA
County Parcel Identification No.(PAN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Ce cation:
35033/37 N W 36-z� 7" W
6.b(are)the well(s): &0ermanent or ❑Temporary Signature of C&gfied Vell Contractor Date
l�v signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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#21 remark 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 (add'See Over'in Remarks Box)'.You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (9� (ft) i
For multiple wells list all depths ifdifferent(example-3@200'and 2 a@1001 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original'form to Division of Water Resources (DWR),
lj water level is above casing,use
f Static water level below top of casing: O (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
6" 24b.For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter: (in-) Program, 1636 MSC,Raleigh,NC 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 rod over 100 000 GPD:Co
�} 11 MSC,Ra eigh,NC 27699-1611 py to DWR,CCPCUA
13a.Yield(gpm) L/ Method of test:AI r Permit Program,16
13b.Disinfection type: Sterllene Amount: c
II
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018