GW1-2021-02581_Well Construction - GW1_20210901

---- — .�•• ror internal Use only:
1.Well Contractor Information:
Ricky Corriher
Well Contactor Name 7 FROM TO DWiffffoN
2464-A �� `.021 S /� ft
Sty! 'Jlllt ft. fL
NC Well Conaactor Certification Number r r,�!;-�'i 1
Frank A. Corriher& Sons "v6I ° ` TO D ,� „ArERLA L
Company Name fL�57� �
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2.Well Construction Permit#:✓ J� FROM TO DiAMElER Tl?QcffivBsg MATF ,L
List all applicable well construction permits(ie.UIC,County,Stare,Parlance,etc) +1 fL 6 1/8 j 1° SDR-21 PVC
3.Well Use(check well use): I fL S I! in
Water Supply Well:
❑Agricultural ❑ ipa�UPublic FAOMn fL DIAb TM SIATSIZE TBICIQVFSS MATERIAL
❑Geothermal(Heating(Cooling Supply) �nf Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared)
01trigation ❑Wells>00,000 GPD FROM TO MATERIAL EMPLACEMEtPI t�raoD&AMouxr
Non-Water Supply Well: i 0 n 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery & fL
Injection Well: I ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
OAglitferr Storage and Recovery ❑Salinity Baaiet FROM TO MATERIAL EMFLACEMF1Yr METHOD
❑Aquifer Test ❑Stotmwater Drainage ft. ft
OExpeumental Technology ❑Subsidence Control fL tt
OGeotherural(Closed Loop) OTraner
OGeothermal QleatmWCooling Return) ❑Other(explain under#21 Remarks) FROM TO DEscie�rao wbr, aonhock ffwn err-)
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4.Date Well(s)Completed: 19—off/�! Well ID# 7 v O- ?9e ft-
5a.Well Location:
Facility/Owner Name ,/ FacilityID#(ifapplicable) ft- ft. 'I
Physical Address,City,and Zip n M
I
CO1mn' Parcel i dentification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
356�ld,one.hw1ong is sufficient) /! 22.C , cation:
�/0 1 `7 `I N 80v-.3q , 17 W
6.Ware)the well(s): &erm went or ❑Temporary Sigaattae of ed ell Contractor'! Date
By signingthis o I hereby certify tha the weU(s)was(wee)constructed in accordance with
f rm
7.Is this a repair to an existing well: ❑Yes or o /SA NCAC 02C.0100 or ISA N& -011C.0200 Well Consbuction Standards and that a copy
Ifthis is a repair,fill out brown well construction information a�explain the nature ofthe ofthis record has been provided to the jrell owner
under#21 rernarke section or on the back ofthis form.
23.Site diagram or additional w� details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pag to provide additional well construction info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See Ovee iti Remarks Box).YI u may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIO S
9.Total well depth below land surface:
For multiple wells list all depths lfdiff-ent(example-3Q200'mr�d 2Q100� Submit this GW-1 within 30 day'Of well completion per the following:
10.Static water level below top of casing: ( ) 24a. For All Wells: Original fdi I to Division of Water Resources (DWR),
If water level is above casing,use"+' Information Processing Unit,16171 ASC,Raleigh,NC 27699-1617
11.Borehole diameter. 6" (-) 24b.For Injection Wells:Copy t II DW
R,Underground injection Control(IUC)
Air Drill Program,1636 MSC,Raleigh,NC� 7699-1636
12.Well construction method: 24c.For Water Supply and Open-hoop Geothermal Return Wel)s Copy to the
(Le-auger,rotary,cable direct push,etc.)
county eavunnmental health depar t of the county where installed
FOR WATER SUPPLY WELLS ONLY:
�( ^ 24d.For Wate r Wei1s p jn rodnc goer 100 000 GPD Copy to DWR,CCPCUA
13a.Yield(gpm) V Method of test Air Perm t Program 1611 MSC,Raleigh;NC 27699-1611
13b.Disinfection type: Sterilene Amount j CAS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6 ti 2018
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