GW1-2022-03696_Well Construction - GW1_20220329

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wen Contractor Information:
Ricky Con iher
FROM 4O DESCRV77ON
Well Contractor Name
2464-A °R -� a
NC Wen Contractor Catificatiaa Number
Frank A.Corriher&Sons Well Drilling, Inc. mom 7O ° MBCXNM MATERML
Company Name �3 _
Z Well Construction Permit#: F1tOM TO DIA1rtLrfER TffiC[OtFSS MATERIAL
List alaWkable well cwtstructimpetmltt#.e.U1C,County,State Varwnce.ex) t1 R f Yft 61/8 'n' SDR-21 PVC,
3.WeR Use(check well arse): ft' ft �-An Uri
Water Supply Well: IntoMI To DIAMETIdt SLOTSIzfi I TMCKNM MATERIAL
CAgricultmal cipaUPublic R ft is
OGeothcurW(Heating/Cool►ng Supply) "al Water Supply(single) R fL in
OlndtsSuial/Commetcial OResidential Water Supply(shared)
Ohrigation OWells>100,000GPD rntont To MATERIAL FdItPiACFFrdk2VrMEMOD&AMOUNrr
Non-WaterSapply wen: 0 ft' 'L Bentmite Hole Plug
OMonitoring ORecovery ft. ft.
Injection Well• R R
OAquifer Rt dwp ❑Groundwater Remediation
OAquifer Storage and Recovery ❑Salinity Barrier - I TO MATEamt, EMPIACF1Nt?NrPIWMOD
OAquifer Test OStormwater Drainage ft ft
OExperimental Technology ❑Subsidence Control ft- %
OGaotim meal(Closed Loop) OTmcer rxxo>.r ro p color s seihoelc sae ea
OC%vdw mal(Hratmg/Coolm in g Return) ❑Other(expla under#21 Remarks) ft - tt
4.Date Well(s)Completed;- (0'--Writ ID# (� ft ft.
Sa.Well Location: r ft. / ft C0r
Facility/Owx(�r�/ — Jed F;7 1D#(ifapplicable) it R.
Ph_" A4dress,City.and Zip ft ft
a t-azj -5 o �4
County Parcel Idemifiariaa No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Ctfwa field,am lat/loag is s�cieat) 1 22 Certifi
350 N 800-,qJr -- 0�9 W
6.IiKs re)the well(s): ent or OTemporary Signature of CertiftdVell Contractor Date
By szVuV dds form I hereby certify dot dx well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: Oyes or o 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Wdl Contimcrion Starsdards and drat a copy
jfdrb is a repair,ftr/out blown well construction bsfotmation and explain the nantre of the of this record ha been provided to the well owner.
repair mtder 921 remarks section or on the back of LAUFform. 23_Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wets having the same You may use the back of this page to provide additional well comuu=on info
co-Ruction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add,Sce Ovet in Remarks Box).You may also attach additional pages if necessary.
drilled / QQ 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` t!�
For mntople wdis liar ell depths tfdjj—(--Vic-3@200'and 2@100') (R) Submit this Gw-1 within 30 days of wellcompletion per the following
10.Static water level below top of casing: (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwmer level is above casbr&use„+„ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6" (le) 24b.For Initmtiion , et Copy to DWR,Underground Injection Control(TUC)
Program.1636 an
Raleigh,NC 27699-1636
12 Well consuuMion ,,od:Air Drill 24c.For Water SaDDIY sud Open=Loop Geothermal Return Wens:Copy to the
(Le- rotary.eab1G directp' etc.) county environmental health department of the county Where installed
FOR WATER SUPPLY WELTS ONLY: 24d.For Water We1Ls rods' 'over'00 000 GPD:Co to D
13a.Yield(gpm) © Method of test
Air Permit Pmgram A SC,Raleigh, C Z7699 1611 CCPCUA
13b.Disinfection type. Ste riIene Amount*
Form GW-r North Carolina Department of Fsvisonmearal Quality-Division of Water Resources MAR 2 9"20 2? Revised 6-6-2019