GW1-2021-02555_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO DESCRIPTION
Well Contractor Name t�t j
2464-A a 1 t
NC Well Contractor Certification Number -
S�U<I�ER,.
Frank A. Corriher & Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
�f
Company Name ft ft in.
��� � L l} '�lYl?IBIt�Il�,,,-
2.Well Construction Permit#: (�J( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) -f1 it V ft 6 111/8 11Oa SDfR-21 PVC
3.Well Use(check well use):
CREE'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ sid cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) eential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) GRO
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft. Be6tonite Hole Plug
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation _.. p
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage it. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soRtrock type,grain size,etc
o n 3o ft. ,(J
4.Date Well(s)Completed: rya Well ID# �� ft. �r� ft. S
5a.Well Location: ft &_
A
// , / c f ft. ft
Facility/Owner Name Facility ID#(if applicable)%7fj ft. ft
sbazA one ft ft
Physical Ad ss,City, d Zip ft it
�;
County Parcel Identification No.(PIN) 4?GU0f1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/lo03-7 �g�g is suffii1et ' Q O a / � b_O // 22.Certifcation: /
6.Is(are)the well(s): (nPermanent- or ❑Temporary signature of ed Well 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 Q1V0 15A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 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: I_ —(ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
24a. For All Wells: Original fort to Division of Water Resources (DWR),
10.Static water level below top of casing: ,, l/ (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater 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 D rI I I 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
[13a.
R WATER SUPPLY WELLSONLY: 24d.For Water Wells produ jing over 100,000 GPD:Copy to DWR,CCPCUA
4 (� Method of test:Air Permit Program 1611 MSC,Raleigh,NC 27699-1611
Yield(gpm)b.Disinfectiontype: Sterllene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018