GW1-2021-02538_Well Construction - GW1_20210805

W L'LL l;V1V b l KU l 11U1V KJI.Uulw (u W-1) For Internal Use Only:
1.Well Contractor Information: S
Ricky Corriher -Well Contractor Name FROM TO DESCRIPTION
2464-A ?o ft Z; fl_
ft. ft i
NC Well Contractor Certification Number
Frank A. Corriher& Sons Well Drilling, Inc. =To
DIAMETER TmcxNEsS MATERIAL
ft i in
Company Name q/2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) +1 tt � ft 6 1/8 1D SDR-21 PVC.
3.Well Use(check well use): �� ft Cl Q tt j�0 v
Water Supply Well: FROM To DIAMETER SLOT SIZE 0 THICKNESS MATERIAL
❑Agricultural �❑ ctpal/Public tt ft in.
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft I ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑lrri ation ❑Wells>100,000 GPD FROM I TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft
OAquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO 1 MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
OGeothermal(Closed Loop) ❑Tracer9999
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRD'1iON rotor,bane sotutoelr sue,etc
d ft o
4.Date Well(s)Completed:_(/Well ID# v ft ?s ft
5a.Well Location: // 7 ft 94 ft
S'Cte'�'hes ft ydrft
Facility/Ow er Name r Facility M#(if applicable) ft ft
ft ft
Physical Address,City,and Zip ft ft
,g, o1 e110 7
county Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient)
35°`� / f�/ t N 80 _ 22.Ce cation:
T r �L ' i,
6.h(are)the well(s): !!'Permanent or OTemporary Signature of ' ed ell Contractor . Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L'l1Vo /SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Ijrhis 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 remarke 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 I GW-1 is nettled. Indicate TOTAL NUMBER of wells ( 'See Ovee in Remarks Box),You may also attach additional pages if necessary.
drilled:
p �OJ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells list all depths ijdifferent(example-3Qa 22000'and 2Q100) ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: O� ( ) 24a. For All Wells: Original j form to Division of Water Resources (DWR),
Ifwater level is above casing,use•'+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6° (�.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county envirotimeatal 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:
Air Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13b.Disinfection type: Sterilene Amount: E
IVY
Form G W-I North Carolina Department Of Environmental Quality-Division of water Resources Revised 6.6-2018
Info�Mattion ro a using Unit