GW1-2022-03060_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Cordher
FROM DESCRiP170N
Well ConuactorNeme TO� �� ft.
2464-A
NC Well Contractor Certification Numbs
Frank A. Corriher&Sons Well Drilling, Inc. EOMI TO OIAMETER THIS ►
Company Name �
Z.Well Construction Permit#: `0/`, FROM TO DIAMETER CKNESS MATERIAL
List all applicable well eonstructionpermits(.e.UK;County,State.Variance.etc.) +'I ft. a� fL 6 1/8 1D' SDR-2`G1 PVC.
3.Well Use(check well use): f 3 Q ft r n / OQaU
Water Supply Well: FROM TO DIAMETER S OTSIZE TIUCKNESS MATERIAL
QA ❑Agricultural ❑ .ipaVPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) fL ft. in.
❑lndustti tYCommercial ❑Residential Water Supply(shared) HOME NNNEWN
OhTi ation OWells>100,000 GPD FROM TO MATERIAL VAPEACEMENr MMOD&AMOUNT
Non-Water Supply Well: A ft 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft- fL
injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation
V ❑Aquifer Storage and Recovery ❑Salinity Barrier F
To MATERIAL EIVIPLACEMFTi1 METH OD
n` ❑Aquifer Test ❑Stormwater Drainage ft
V/ ❑Experimental Technology ❑Subsidence Control �
❑Geothermal(Closed Loop) ❑Tracer
TO DESCREMON Color,Ivadness,s ilreek am,etc.
❑Geothermal(FIeating/Cooling Return)
❑Other(explain under#21 Remarks) � f44.Date Wetl(s)Completed:� O?2 Well ID# eqft• 0%45a.Well Location::10/J a71 a/1 `aOtSe� �Facility/Owner Name v Facility IDk(if apphcav ft
i T
�Ol2 �'1 exf(12a fed Gr,�45510�
Physical A�►City,and Zip ft. f
L NEU
County Parcel Identification No.(PIN) 9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iaUlong is sufficient) 22.Certifi n•
35 p 19 N 80 o-3? r �U" W ilk' v l
6.*are)the well(s): ermanent or ❑Temporary Signature of Certified well Contractor Date
i
By signing this form/hereby certify that the we11(s)was(were)constructed in accordance with
7.Is this a repair t0 an existing well: ❑Yes or o ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and Drat a copy
If this Is a repair,fill out brown well construction injbmiation and explain the nature of the of this record has been provided to the we11 owner.
repair under 921 mmarla section or on the back of das form. 23.Site diagram or additional well details:
&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(AV-1 is needed Indicate TOTAL NUMBER of wells (add:see Over,in Remarks Box).You may also attach additional pages if necessary.
drilled. Q 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -3 U 5 (ft.) Submit this GW-i within 30 der of well completion
For multiple wells list all deptiu fdii ferem(example-3@200'and 2@100) w n days p etion per the following:
10.Static water level below top of casing: ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwacer level is above e�hi use.,t„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1
11.Borehole diameter. 6' (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Air Drill
(Le Well construction cable,
method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rohary,cablq direct push etc.)
county environmental health department of the colmty where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Dr•oducine over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) R Method of test
Air Permit Program,1611 MSC,Raleigh,NC 27699-161
13b.Disinfection type: Stenlene Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018