GW1-2022-09479_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD(GW-1) r For Internal Use Only:
1.WeR Contractor Information:
Ricky Corriher
FROM TO I MAMMON
weu Co�roorName
2464-A ft ft.
ft. � I
NC Well ContractorCartificationNnmber
Frank A. Cordher&Sons Well Drilling, Inc. °M TO D =TMCXXMIMXIVAL_
n - ft- i ;n
CoWaayNata /2.Well Consiruction Permit#: FR°M To DiAM€rEx TffiCtae>ESS MATt>;ruAL
Lisr all applicable rro?ll construction pertniu(ce UIC,County Sire Yariatce eta) +1 it 1 ib 6 1/8�% + 1D SDR 221 PVC
$: C 3.WeII Use(check well ru tti se): �ft rt
water,Supply Well-
I TO DI45E31EB I SLOTS= TMCWaSS I MATERIAL
❑Agricultual ❑ lit fr. ft fn.
OGeothermal OleadneCooling Supply)J water Supply(single) n ft in.
oludustrial/Corarnercial ❑Residential water Supply(shared)
❑Tar on ❑Wells>100,000GPD FItO1H TO MATERIAL EB0?LACZBUN'METWD&AM0uxr
Non-Water Supply Well: \ I 0 % 22 fL Bentonite Hole Plug
OMonho&g ORecovery ft, it
Injection Well: ft ft.
OAquifer Recharge ❑Groundwater Remediation
t7Aquifer Storage and Recovery ❑SalinityBarrier FROM TO MATERIAL IhUTACDWI'IWrK0D
❑AquifefTest ❑StoffiwauwDtainage ft ft
❑Experimental Technology ❑Subsidence Control & ft
❑Geothemtal(Closed Loop) OTMEW -
❑Geotheffial M ating/Codl g Return) [71�( m lain under#21 Remarks)) FROM To DBSCRD?TION cobr tuautaess soiYroek eta
ft fti
4.Date Well(s)Co,mple�ea: �- weum# Q L led ft n �
Sa.Welt Location: 6 O
l
otw n etf.S Pernr�r�e�.a I' ck
Facility/q� Name l �t F '' (ifapplicabk) �� zes - •- yc •r
b5bitl C� ft ti` I t .y O—
PhrAd&4< and Zip ft ft
a�1;116I a .
County a Parcel Identification No.(PIN) „?Jn PtoGW-n! *�Unit
5b.Latitude and longitude in degreesimmntes/semnds or decimal degrees:
C K am Ongiss ) 80 j 22-c
35lf am
6.Xam)the well(s): ermanent or ❑Temporary Sigoatuue of ed well Contractor + Date
Bvsigning this form"I hereby—fv lthe wU(s)xuzs(—v)cow&ucwd in accordance with
7.Is this a repair to an existing well- ❑Yes or ;410 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conswcaon Saadards and deck a copy
If dis is a repair,fill out brows well construction information an esplain the nature of&a of this record has bem provided to ate well owner
repair rider#21 retnw*y section or on the back ofdus form.
23.Site diagram or additional wen detain
&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 needed Indicate TOTAL NUMBER of wells (a See Over'in Remarks Box).You may also attach additional pages ifnecessacy.
drilled
�i 24.SUBMITTAL INSTitUCTIONS
9.Total well depth below land surface-
Fory ( ) Submit this GW-1 within30 dad of well completion
multiple xvlis Liss all depths ifdiffevnt(example-3@200"and�00) 9s mp per the following:
24a. For All Wells: Original Ifoffi to Division of Watei Rwources,(DWR),
fu Static water ab level below top of casing: ( ) Info�tion Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijx,ata�levrl is above casing use"+" -
11:Borehole diameter 6" (m,) 24b.For Infection Wells:Copy tl DWR,Underground Injection Coti�oI(IUC)
Program,1636 MSC,Raleigh,NYC 27699-1636
12 Well cons rn tin.method:Air Drill 24c.For Water Supply and ODIen'-Loop Geothermal Return Wells:Copy to the
C'e ­M rotary,cabs'direct push.etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells prodttc
;mg over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 SC,Raleigh,NC 27699-1611'
13a.Yield(gpm) v Method of best;AU M
13b.Disi.actiontype:Sterilene Amunt:
Form Fiw-1 North Carolina'Depactmenr of Environmental Quality-Division of Water Resources Revised 6.620is