GW1-2021-06464_Well Construction - GW1_20211022

WELL CONSTRUCTION RECORD For Intemal Use Only:
1.Well Contractor Information: "
Ricky Corriher
ContractorWell �,:`t FROM TO DESCRIPTION
2464-ANC ,z� 'v /4 /r' e
Y
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER THICIQVESS MATERIAL
ft ft in
Company Name -7
2.Well Construction Permit#: �'/( (�f 0 FROM TO DIAMETER THICKNESS MATERIAL
Gist all applicable well construction permits(Le.UIG County,State,variance,etc.) +1 ft. /_ ft 6 1/8 in SDR--21 PVC
3.Well Use(check well use): 9 [t tt rn p
AJ
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unmcipal/Public ft ft in.
❑Geothermal(li-ting/Cooling Supply) Residential Water Supply(single) ft ft l in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
. .... . .. ..
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it 22 Be6tonite 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 ft it
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DESCRIPTION lor,hardness,zaillrock sae,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft e h r
4.Date Well(s)Completed: Well ID# 50 ft '!�/ti' �^ct�/L
5a.Well Location: t-v ft ! d' &
ft y ft
Ffacility/Owner Nude Facility ID#(if applicable)
ft ft
cs� ft fL
Physical Address,City,and Zip ft ft
Ro ltiCz/7
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert cation-
35',3 / �G t N 80 93 7`' W
6.Is(are)the well(s): hA.'rmanent or ❑Temporary Signature of CZsffied Viell 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 16N 15A NCAC 02C.0100 or ISA NCAC 02C.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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
wed' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �� (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@10&)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: / 0 (ft) hnformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
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
24c.For Water Supply and Open-Loop Geothermal Return Wells: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 producingover 100,000 GPD:Co to Copy DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: C`a
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6r6-2018