GW1-2021-02551_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: ��
Ricky Corriher
Well Contractor Name TO DESCRIPTION
2464-A SEP (ooe�s( G O ft. ;j--
NC Well Contractor Certification Number �3ONN(�SBC��O� t
Frank A. Corriher& Sons Well Drilling, Inc. FRUM TO DIAMETER THICIINESS MATERIAL
ft ft in.
Company Name FROM
D _.. _ --
2.Well Construction Permit#: TO DIAMETER TIHCKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,Coun(y,Stare,Variance,etc.) +1 ft I ft 6 1/8 1- SDR-21 PVC
3.Well Use(check well use): 0 ft l (J3 `t. 5� rn
Water Supply Well: FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural Wesidential
unicipal/Public it ft in.
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft Ben'tonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater RemediationOMNI—
_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer Kim
❑Geothermal(HeatingJCoolinGg�Return) ❑Other(explain under#21 Rem FROM TO DESCRIPTION(color,hardness,soilfrock etc.)arks) rt 4J�) to �
ej
4.Date Well(s)Completed: / Well ID# qd
ft d it
5a.Well Location: - ! r o`t 3 `t 5 v c9C.11i
r'la _ '���
Facility/Owner Name Facility ID#(if applicable) M It.
14 /9 �� �� f'a/r�S ,��- rr oo/ G ft ft.
Physics Address,City,and Zip ft %
I Alykw a i�`OD
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) �� �� �j 22.Certifcation:
35°3� `37ii N 80-, w
6.Is(are)the well(s): Wermanent or ❑Temporary Signattne of ed ell Contractor Date
By signing this form,I hereby certify the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: []Yes or o, 1 SA NCAC 01C.0100 or 15.4 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 remarla 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.
drilled' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft)
For multiple wells list all depths if different(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
4/024a. 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(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AI r Drill 24c.For Water Supply and O t pen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
L13d
TER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Co to D
`� Perm rt Pro PY WR CCPCUA
(gpm) O Method of test•AI r > �1611 MSC,Raleigh,NC 27699-1611
fection type: Sterilene Amount: Ca�S
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018