GW1-2021-00436_Well Construction - GW1_20211206

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRII'770N
Well Contractor Name tt ft
2464-A it
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. I FROM TOfL DIAAMTcu THICKNESS I MATERIAL
Company Name
2.Well Construction Permit#:� FROM TO DIAMETER THtclavEss MATERIAL
t) List all applicable well construction permits—(i.e.UIC,County,State,Variance,etc.) +1 ft 6 1/$ m SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: FROM TO DLIM7R""
SLOTSIZE THICIQHESS MATERIAL
❑Agricultural ❑ ctpaUPublic ft ft.❑Geothermal(HeatiagfCooling Supply) idential Water Supply(single) fts
OIndusttiallCommercial ❑Residential Water Supply(shared)
❑Itri ati0n ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOr1NT
Non-Water Supply Well: 0 ft 22 ft Benton t!e Hole Plug
❑Monitoring ❑Recovery ft. tt
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation --_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEbrr METHOD
❑Aquifer Test ❑Stormwater Drainage tt ft
❑Experimental Technology ❑Subsidence Control ft f
❑Geothermal(Closed Loop) ❑Tracer
TO DES O color,bpdne4 soillrock ere
\/►NNl ❑Geothermal(Heating/Cooling
J Return). ❑Other(explain under#21 Remarks) © ft ft
?' ) 4.Date Well(s)Completed:G! ` Well ED# ft 7� ft.
5a.Well L n: -2 0 ft 41 ft
oc ' �8
C 1C !e ft o ft
F Ili M#(ifa licable) ft. it.
Facility/Owner ry PP
* ft. ft
ft ft ' '
Physical Address,City,and Zip
cc ty Parcel Identification No.(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ;1 22.Certification:
n
35p ;5Q I L] 1 N 80 0 3 3V W
6.Is(are)the well(s): OPermanent or ❑Temporary
Signature of CTitified Will Contractor Date
By 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 o 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0200 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 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
( Sce Over'in Remarks Box).IYou may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0� (f" Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdii ferent(example-3Q200'and 2@1001
/y 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: // (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
bn 24b.For Injection Wells:Copy to DWI?,Underground Injection Control(IUC)
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 producing over 100,000 GPD:Copy to DWIt CCPCUA
/ Air Permit Program,1611 MSC,RaI eigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Sterllene Amount: /1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018