GW1-2021-02336_Well Construction - GW1_20210722

vv r.LL%-vi,40 1KUL;RUIN RECORD (GW-1) For Internal Use only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Nama FROM TO DESCRIPTION
2464-A 3 aft.
iL rL
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. mom To DUMETER TMCXNM MATER[a
ft. ft. in
Company Name f'�''"`��
2.Well Construction Permit#: �/ ! (l aoM To nrnM> rielz T> CfQvss MATFRfnt,
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) +1 n- l fL 6 1/$ DR-21 PVC
3.Well Use(check well use): 71 fL fL to l U
Water Supply Well: FROM I TO DIAMETER SLOTSIZE THICKNESS MATERtAI
❑Agricultural ;rid
ft. fL
OGeothermal(Heating/Cooling Supply) ential Water Supply(single) fL ft in
Olodustrial/Commercial ❑Residential Water Supply(shared)
01ni ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMEWMETHaD AMatmr
Non-Water Supply Well: 0 ft 22 fL Belitonite Hole Plug
❑Monitoring ORecovery fL ft.
Injection well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery OSaliDity Barrier FROM TO MATERIAL lmalm CE11fENT METHOD
OAquifer Test OStorrawater Drainage ft ft
❑Experimental Technology OSubsidence Control ft. h-
ii
OGeothermai(Closed Loop) ❑Tracer
DGeothernial COO m
Return) ❑other(explain under#21 Remarks) FROM TO DESCRIPTION tobr hardy aoiYrock em
TO
O ft. A,
4.Date Well(s)Completed: Well ID# Sr�r3 fL 25 0-
5a.Well Location: G 5-`rL Ale-
ft. G
, fL
/F-•l1t�/ l/f1.C" clG, !,`'�i
F/a/cility/owner Name Facility ID#(if applicable) ft. ft
( � L �/t/A/� y ►=-1= �+rc'GIs /l se�6if �� fL f
�— ! ft ft
Physical Address,City,and Ztp
County Parcel identffic on No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,am latttllong is sufficient) 22.Certifica tion-
(5&w0 £ ✓ /r N 80', W
_f� ot
/
6.Is(are)the well(s): f6Permanent or ❑Temporary Sigzaluse
of . ' ed Well Conttactor: k5
.t Ilv 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: OYes or �Ellvo I JA NCAC 02C.0100 or ISA NCAC 02C.0200 ff ell 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 an 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 T 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: (ft)
For multiple wells list all depths if different(example-3@2/0�and 2@1001 Submit this GW-1 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),
[jwater level is above casing,use"+" Information Processing Unit,1617i MSC,Raleigh,NC 27699-16I7
11.Borehole diameter: 6" (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Prograin,1636 MSC,Raleigh,NC+27699-1636
12.Well construction method:Air D rl I I 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 Droduciniover 100,000 GPD:Co to D
Al r Permit Program,1611 MSC,Raleigh;NC 27699-1611 Copy CCPCUA
13a.Yield(gpm) Method of test: �
13b.Disinfection type: Sterilene Amount: {
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018