GW1-2021-02549_Well Construction - GW1_20210901

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher ''; +'j
Well Contractor Name -° FROM TO DESCRIPTION
2464-A 12021 Zz0ft
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SC tJ1111 f
NC Well Contractor Certification Number -3"t 91L
RC nttase
Frank A. Corriher & Sons gU0. �v g I �" FROM TO DIAMETER THICKNESS MATERIAL
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ft ft. in.
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Company Name `✓� x, - �t�LtBl�i.' :eoth'eina�_los-..."oo.
2.Well Construction Permit#: FROM TO I THICKNESS I MATERIAL,
List all applicable well construction permits(i.e.UIC,Coumv,State,Variance,etc.) +1 ft.' ft 6 1�$ in S R-21 JPVC
3.Well Use(check well use): 0 d ft ft G;n. Q
Water Supply Well: o
FROM TO DIAMETER STAY SIZE THICKNESS MATERIAL
DAgricultural D cipaUPublic ft ft. ;n.
❑Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft in
❑[ndustrial/Commercial ❑Residential Water Supply(shared) GILO
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 rt Bentonite JHole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation •^ it. ft
❑Aquifer Storage and Recovery ❑Salinity Barrier
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. fc
❑Geothermal(Closed Loop) ❑Tracer ODD `, SZE
c .a: tloiaPshee_. sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DES RIPTI N color,hardy ,soiYrock a size,eta)
tJ
pL ft fL Ie
4.Date Well(s)Completed: rl Well ID# ft 1C,' ft
5a.Well Location: D ft ft Q
—I- Fny- - L C 2.ft rt
Facility/Owner Name Facility ID#(if applicable) ft ft
S-/,' - - � c 1 GAP ft. ft
Physical Address,City,and Zip tt ft
Ro �✓G/7 a?r - I
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifcation:
35°3,S` ,01/ N 80°-3 6�� ��' W
6.Is(are)the well(s): ermanent or ❑Temporary Signature of C ri ed ell Contractor V 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 4o 1 SA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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 Over in Remarks Box).You may also attach additional pages if necessary.
drilled:
24-SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: b M-)
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100) 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),
Ifwater level is above casing,use"+ Information Processing Unit,1617'MSC,Raleigh,NC 276994617
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
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producintr over 100 000 GPD• Co to D
13a.Yield(gpm) Method of test:
Air Permit Program, 1611 MSC,Raleigh,NC 27699-1611 PY �'R CCPCUA
136.Disinfection type: SterileneAmount:
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Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018