GW1-2021-02519_Well Construction - GW1_20210901

TV JU L U%—%Jilva t JMU1.11V1,4 I(ECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
Well Contractor Name FROM TO DESCRIPTION
2464-A eft a i) ft
ft it
NC Well Contractor Certification Number _
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER THICICNESS MATERIAL
ft ft in.
Company Name / ^ _
2.Well Construction Permit#: OL 7 FROM TO f DIAMETER nUCKNEss MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) +1 ft "i � ft 6 1�$' In- SDR-21 PVC
3.Well Use(check well use): Q ft ft d
r
Water Supply Well: FROM I TO DIAMETER I SLOTSUZ law
THICICI�SS MATERIAL
❑Agricultural ❑ cipal/Public ft M in.
❑Geothermal(Heating/Cooling Supply) Wesid..tial Water Supply(single) ft ft in
❑lndustnal/Commercial ❑Residential Water Supply(shared) --
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 22 it Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft ft
OAquifer Storage and Recovery ❑Salim Salinity FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer ._.. _._.. _ . ..
Pori
FROM TO DESCRIPTION eobr,6atdn
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �. ;Yrock size,etc)
® ft S ft
4.Date Well(s)Completed: ��I I- I Well ID# 3s ft 2ft yt
9
5a ll Location: Ztt /`_ej
ti n �� ft ft
Facility/Owner Name t, acyI#(if applicable) ft ft
`-) �D - o'i S� �o ado n o�� ft t
Physical Ad s,City,and Zip ft It, Unit
C Ob 0\rrlt5
U
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.Certifcation•
6.Is(are)the well(s): permanent or ❑Temporary Signattae of ed ell Contractor; Date
By signing this form,I hereby certify that the well(s)was(were)constmcted in accordance with
7.Is this a repair to an existing well: ❑Yes or QNo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 well Construction Standards and that a cape
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See O'er 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-3Qa 100'and 2Q100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources DWR,
10.Static water level below top of casing: �5 L/ (B,) b'� ( )
If water level is above casing,use"+' hlformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
11.Borehole diameter: 6- (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Drill Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:(i.e.auger,rotary,cable,direct push,etc.) nd 24c.For Water Supply a Open-Loop Geothermal Return Wells:Copy to the
cotmry environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin¢over 100 000 GPD Co D
Permit Pro 1611 MSC,Raletgh,NC 27699-1611 Copy to CCPCUA
13a:Yield m f� A S'�:r
(gP ) Method of test• I r
13b.Disinfection type: Sterilene - Amount: caA5
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018