GW1-2021-02535_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM I TO DESCRIPTION
Well Contractor Name it 10 d ft
2464-A tti ft d
i
NC Well Conhactm Certification Number --
Frank A. Corriher & Sons Well Drilling, Inc. FROM Dte�nv7Fn TfficlavEss MATE
fL tt in.
Company Name
2.Well Construction Permit#: i�,(/ 'a(/ FROM TO DIAMETER TffiCffivESS MATERIAL
List all applicable well construction permits(I.e.UIC.County,State,Variance,etc.) +1 ft 34'�fL 6 1/8 in SDR-21 PVC
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SI OT SIZE TIIICICMS MATERIAL.
❑Agricultural ❑ cipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft in
1 .
❑Industrial/Commerciai ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O rt 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft %
❑Aquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATFRUL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft- ft.
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESgWnON fpbr,h ess,soWn k d..,0.)
�7 9 0 % rL
4.Date Well(s)Completed: — of Well ID# 3 e) ft
Sa Well Location: p LJ�
G/ l� ft iL
Facility/ ame / d/ ility ID#(if applicable) it it
it
Phys s,City,and Zip ft [L
Karma /-7 3�1 Gya -
County Parcel Identification No.(PER) V 11n11
InSolr',a 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: MNS ed'on
(if well field,one lat/long is sufficient) 22.C cation:
35°'3/ j dQ N 80�a` - ��/ W ����>/
6.Is(are)the well(s): dermiaent or ❑Temporary Signature of ed ell Contractor Date
By 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: ❑Yes or W. 1 SA NCAC 01C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a copy
Ifth&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:
S.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.
dried: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` (H) Submit this GW-1 within 30 da s of well completion
For multiple wells list all depths ifdifferent(example-3©200'ands 2@1000 , Y p per the following:
10.Static water level below top of casing: C9 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwaater level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (;n,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
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
(i.e.auger,notary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producma over 100,000 GPD:Co to D
13a.Yield(gpm) nO Method of test:Ai r
Permit Program,1611 MSC,Raleigh,NC 27699-1611 Copy CCPCUA
13b.Disinfection type-.Sterilene Amount: a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018