GW1-2021-00426_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher - -
Well Contractor Name FROM TO DESCRIPTION
2464-A p rt 1 q d ". ' 5 4,
ft ft.
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft tt in.
Company Name __ T
/b 2.Well Construction Permit#: 1�© � (J FROM TO DIAMETER ziucfavess MATEIAL
List all applicable well construction pernrrts(i.e.UIC,County,State,Variance,etc.) +1 ft �(C ft 6 1/8 in. SDR-21 PVC.
3.Well Use(check well use): 7 tt ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIICKNESS MATERIAL,
❑Agricultural ❑ cipa/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U rt 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater RemediationMEOW
_ _w
❑A uifer Storage and Recovery ❑Salim Barrier
r1 g r7 tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control it ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal FROM TO DESCRIPTION color,hardn soillrock size,etc.
AV
(Heating/Cooling Return) ❑Other(explain under#21 Remarks) tt rt
DJ-
4.Date Well(s)Completed:1 -g- a Well ID# Q tt ft. 5 C't M
5a.Well Location: ft ft <e e L
LG' a E'e. rt q' ft
Facility/Owner Name y� Facility ID#(if applicable) /� ft ft
Ab lyc ft ft
Physical Address,City, d Zip ft %
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
ssm
(if well field,one lat/long is sufficient) 22.Certif cation•
35a3� / Ll Ll N 80O ��/_ �Q l / W
6.Is(are)the well(s): �ermanent or ❑Temporary Signature of rE ed ell Contractor Date
L y signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o ISA NCAC 01C.0100 or I 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 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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _! (ft)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I001 Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: ( (ft 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
Ijwarer level is above casing,use"+" g gh,
11.Borehole diameter: 611
(in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC,27699-163 6
12.Well construction method: 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 producin¢over 100 000 GPD•Copy to DWR,CCPCUA
13a.Yield(gpm) /�� Method of test:AnnI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018