GW1-2021-00421_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -Well Contractor Name FROM TO DESCRrPTTON
12464-A !l� 3 t
Tt ft.
NC Well Connactor Certification Number -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO D T TBICKNnS MATERIAL
ft ft in
Company Name � .. iy
�< 2.Well Construction Permit#: EOMI TO DIAIYtETER 'IHICIMSS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +� tt C 7'�) tt 6 /g 'n SD R-21 PVC
3.Well Use(check well use): ft -z S/ Q
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ unicipal/Public fL ft I in,
❑G eothermal(Heating/Cooling Supply) idential Water Supply(single) M ft �!in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
OIrrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD k AMOUNT
Non-Water Supply Well: 0 Tt 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
up M- M
OAquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal FROM DES N color,hardness,soiYrock sire,eta
(Heating/Cooling.Retum). nn❑Other(explain under#21 Remarks) O ft a� ft
4.Date Well(s)Completed: `d Well 1D# ft ft & -ewl u re ce o
Sa Wellll Location: fL -6 � 'd Ace— �y�
01 Ui, t �� ft ft
Facility/Owner Name Facility ID#(if ap licabllee) ft ft
ft. ft
Physical Addr City,and Zip ft ft DEC
Ca art (,c,S
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.C cation•
35� 3 G t gig N 80 O � '� �-'� �W „
l- gl
6.Is(are)the well(s): hlr-e manent or ❑Temporary Signature of ed ell Contractor Date
By signing this form,I hereby certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or SKO /SA NCAC 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out brown 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 O'ee in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3 @2 00'and/2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing- d V (fL) 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
.Well construction method:AI r Drill 24c.For Water Supply and Opi
(in-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 producing over 100 000 GPD-Copy to DWR,CCPCUA
13a.Yield(gpm) Q Method of test:Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type:.Sterilene Amount Ca
Form aW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018