GW1-2021-05902_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: �`` (EV
Ricky Corriher Inv* v -
Well Contractor Name ,%— M TO DESCRIPTION
2464-A ��� �g�n9 C ft ft- 5�
NC Well Contractor Certification Number 3t�n son `
Frank A. Corriher& Sons Well0463gy'I�ic. FROM TO DIAMETER THICKNESS I MATERIAL
ft ft in.
Company Name f _.
2.Well Construction Permit#: iQ ( F
FROM TO DIAMETER I TffiCKNESS I MATERW.
List all applicable well construction permits(Le.U1C,County,State,Variance,etc) +1 M SDR-
fL It 5- 21 PVC.
Q
3.Well Use(check well use): 6
Water Supply Well: FROM TO DIAMETER SLOTSUE THICKNESS I MATERIAL
❑Agricultural ❑ cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidetift l Water Supply(single) ft ft in.
❑lndustrial/Cornmercial ❑Residential Water Supply(shared) '
Mitigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 rt Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACFA!1M METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control ft
❑G it
eothermal(Closed Loop) ❑Tracer
FROM TO DESCRH O cobr hardness,solYmck
❑Geothermal sing etc)
(Heating/Cooling Batton) ❑Other(explain under#21 Remarks) � rt ft,
4.Date Well(s)Completed:/to Well ID# 2-0 ft ft-
Sa.Well Location: -L fi rt �u g J�yb C,QytJ
Pyramic, 6 ft 90 ft t.L ra
Facili /Owner Name ,; Facility ID#(if applicable)e) �C7 ft ft
/S/ / c17-G�6 Ad �b12 ca� ft ft
Ph s,City,and Zip ft ft.
a c rr m
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one lavlong is s fficient)
22.Certifcation:
35 ,�-F-3 1 -1 N 80 7 W
6.Is(are)the well(s): kPemneut or ❑Temporary Signature oftZsdied Well Contractor Date
By signing this form,/hereby certifv'that the wells)was(were)constructed in accordaxce with
7.Is this a repair to an existing well: ❑Yes or W. 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (� (fr) Sabit this GW-1 within 30 days
For multiple wells list all depths if different(example-3Q200'and 2@100) m s of well completion per the following:
10.Static water level below top of casing: 4/0 M) 24a. For All Wells: Original form to Division of Water Resources (DWR),
ifwater 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)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:
Air Drill
(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 producing over 100,000 GPD: Copy to DWR CCPCUA
'O Air Permit Program,1611 MSC,Raleigh NC 27699-1611
13a.Yield(gpm) Method of test: /
13b.Disinfection type: Sterilene Amount:
i
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018