GW1-2022-03068_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Ricky Cordher
Well Contractor Name FROM TO DESCRIPTION
2464-A lo�� It
ft tL
NC Well Contractor Certification Number —
Frank A. Coniher&Sons Well Drilling, Inc. FROM TO D 8RIAI
n ft. in.
Company Name /
2.Well Construction Permit# O� 0� FROMTO DIAMETER THICIWESS Mp7 F2tIAy
List aU applicable weU twnsnueiion permits r.e.UIC,County,State,Variance,etc) +1 iL ft 6 1/8 in- SDR-21 PVC
3.Well Use(check well use): n. r/
Water Supply Well: IrttoM To Dw�rER swrsux MATERIAL
❑Agriculhual 0 cipal/Public ft ft in.:
OGeothermal(Heating/Cooling Supply) idential Water Supply(single) ft in.
01ndustrial/Comm«cial ❑Residential Water Supply(shared)
-13hrigation ❑Wells>100,000GPD MATERIAL MMOD&AMOttivr
Non-Water Supply Well: O ft 22 ft Bentoriite Hole Plug
❑Monitoring ❑Recovery, fL ft.
Injection well:
R ft.
❑Aquifer Recharge ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACFA6TTI METgOD
❑Aquifer Test OStormwater Drainage ft it
❑Experimental Technology OSubsidence Control fc ft
❑Geothermal(Closed Loop) ❑Tracer
PROM TO DESCRIPTION edor Iraxdonsq aoiteck
❑Geotherm l(Hew Return) ❑Other(explain under#21 Remarks) O ft. R em
4.Date Well(s)Completed: ."13` Well ID# 0 >t fi S�' O
Sa Well Location:
ft- -Iff j Lv Cjra
o,/4:-- e fL ft.
Facility/OwnetName Facility (if applicable)) fL fL
C ae 114 fL ft. MAR 0 7 2029 11(g'?- ,-/,'
Physical Cary,and Zip ft ft.
C,rb -�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen field,one lavlong is sufficient)
�t t it 22.Cerdfi lion:
3503 7 N 80C�- S _ W
6.Is(are)the well(s): ermanent or OTemporary Signanue of ell Contractor I?aoe v�
�� By signing this form,I hereby cenify d'al'the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well• O Yes or l o 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards turd that a copy
If this is a repoin fr/l out known wdl construction h fonnaurin and ezplain the nature of the ofthls record has been provided to the welt owne,.
repair under 921 remarks section or on the back of thh 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 GW-1 is heeded Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
n 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `�
For muluple wells list all depths fdifjerent(example-3©200nand 2JQ�t00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Ot J (M) For All Wells: Original fain to Division of Water Resources (DWR)
Ifwater tevet is above easing,use + Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" 010 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
12.Well o�O°method'rotary,cable dux,push
(Lt.•� etc.) Dlyan 24c.For Water Suod Oceno-LooD Geothermal Return Wells Copy to the
� coumental health d epartatent Of
[tty envtrort the cotutty where installed
FOR WATER SUPPLY V1'�LLS ONLY: 24d For Water Wells Drodncine over 100 000 GPD Co to D
6 Permit Pro Copy WR CCPCUA
13a Yield(gpm) Method of test Air gram 161 I MSC,Ralelgh,;NC 27699 1611
13b.Disinfection tyW.. Sterllene Amount: G
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources RevL-d 6-6-20is