GW1-2022-01599_Well Construction - GW1_20220204

WELL CONSTRUCTION RECORD(GW-1) For Internai Use Only:
1.Well Contractor Information:
Ricky Cordher FROM TO I DFSCRUTION
Well Contractor Name ft.
2464-A I
NC Well Contractor Certification Number _
JAbWM THICKNESS
Frank A. Corriher&Sons Well
^Drilling, Inc. FROM ft. 1O ft. D
Company Name
5FROM TO DIAMETER TImCId'tESS MATERIAL
2.Well ConstructionPermitft- +1 ft. �! ft. 61/8 '" SDR-21 PVC
List all applicable well construction permits(.e.U1C,County,State.Yartarce,etc)
Sal ft .ein.
3.Well Use(check well use): �f
Water Supply Well: FROM TO DIAMETER SLOTSIIE TH1C[QVFSS MATERIAL
p OAgricultutal
p lcipal/Public R ft 1n.
�1 ❑Geotherral(Heating/Cooling SuPPIY) idential Water Supply(single) R ft
Cj ❑Industrial/Cornmercial pResidential Water Supply(shared)
p W ells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri lion p �- 22 �- Bentonite Hole Plug
�J Non-Water Supply Well:
❑Monitoring
❑Recovery
Q j Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM 70 fL MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
V ft ft
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIFfiO color hardness sol/ro&tylie,vain sim,ea.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: Well ID#
' e- r'ti-
5a.Well Location:
In P L fappcb 7Fa D#(ie9
Facility/Owner Name fL
Physical Address,City,and ZipnO�
Aol c -�,� /,[J� 6
Bann, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certifi lion:
350,-34 �O N 800
Signamte of C ell Contractor Date
6.Is(are)the well(s): Wermanent or ❑Temporary
By signing this form,1 hereby certify that the well($)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IQ1Vo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
o this record has been provided to the well owner.
If this is a repair,fill out known well construction information nerd explain the nature of the f
repair under#21 remarks section or on the back of this farm. 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
(add'See Over in Remarks Box):You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: _ 2.4.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (fL) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths ifd ffereni(example-3@200'and 2(Qa 100)
24a. For All Wells: Original,form to Division of Water Resources (DWR),
10.Static water level below top of casing: (N-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
n 24b.For Infection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter:6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc-) county environmental health department of the county where Installed
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water"Raleigh,
over 100,000 GPD:Copy to DWR,CCPCUA
5 Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
139.Yield(gpm) Method of test: /�
13b.Disinfection type: Sterilene Amount: C- aip5
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018
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