GW1-2021-02539_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ,-�°�!` �
Ricky Corriher CI Q- - --- -
Well Contractor Name FROM TO DESCRIPTION
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2464-A slE `� coce�S�� t �6 " 5
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NC Well Contractor Certification Number
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Frank A. Corriher& Sons Well M g K FROM TO DIAMETER THICKNESS MATERIAL
ft ft in
Company Name V D FROM DG1M
2.Well Construction Permit#: ( ETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) +1 [t L16 ft SDIR-21 PVC
3.Well Use(check well use): ft 2 ft 5 n•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) , GAO
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: A It- 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage rt tt
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 0 n a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness aoitlrock sae etc
49 ft 3 it D -
4.Date Well(s)Completed:-7- l4/�-1 Well ID# J 4P M 1.�Z ft 5 p C
5a.Well Location: �tt ft
.J n Cod ry?0 at c it ft
Facility/Owner Name Facility 1D#(if applicable) ft ft
6 5— J�4m 6;V119/2g/ ft
Physical Address,City,and Zip
it ft
f� 2
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(35lo el /� �/ong is ient)N 80" -23 7 >1 W 22.Certifcation•
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6.Is(are)the well(s): &4rmanent or ❑Temporary Signature of C.TrAed Viell Contractor Date
1 By signing this form,I hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or a, 15A NCAC 02C.0100 or 15A 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
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@I00)
-Y G (f�) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfwater level is above casing,use
11.Borehole diameter:
6" (in.) 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
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Well1611 MSC,Raleigh,NC 27699-1611s producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) O Method of test:Air Permit P ro gram, i
13b.Disinfection type: Sterilene Amount: CG
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018