GW1-2022-10687_Well Construction - GW1_20221205

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher
FROM TO 1)nC MM0N
Well Contractor Name
s 3aS ' -7 4�
2464-Aft. ft. ; .
NC Well Contractor Certification Number -
Frank A.,Corriher&Sons Well Drilling,;Inc. °M TO MAME"M TMCRNM Mn tut
\ ' ft ft- f m /
Company Name � �,
2.Well Construction Permit#: I M ro DIAMETER TIUCSNESs MATMUAL
ListaUapplieabkwrUconstmcdonpmnts(ie.U1C,County,state,T'afianceeta) + ft '.� fL 61/8`, lr SDR-21 PVC
fL
3.Well Use(check well ace): 1 2 a-3 (,� A� 4
i
Water Supply Well: 1 M TO DIAMHIIER SLOT SIZE TffiCKNTsSS MATERIAL
❑Agtictlttrual ❑M clpallPublic it it it
❑Geothermal(Heating/Cooling Supply) esidential Walter Supply(single) ft fL in
❑Industrial/Commercial ❑Residential Water Supply(shared),
111rri 'o ❑Wells>100,000GPD TO MATF.RM"L EMPLACEMENTMETJ3oD&AMOUNT
Non-Water Supply Well: I 0 ft 22 fL 13e66nli6' Hole Plug
❑Monitoring ❑Recovery ,ft. ft.
rOAqmfer
on Well: _ ilt fL
fer Recharge s a ' t� CYodwater Remediation —
`. i� a 1 p
Storage and Recovery ❑SalnityBarrier, OM TO MATERLA- EMYLACKMZNTMETHOD
h 20ntormwater IiDtatnage ft. ft
❑Aquifer Test .-DECL lip
❑Experimental Technology ❑Sub ni&nce Control ft ft
i^;1i.':..',fi" uit Ij;r
❑Geothetmal(C1os.FodpH gtacer I,
r�ld',•'l�zi��x �`,� OM TO D&SCRIPITON ea Lardneat.seWock ete.
❑Geothermal(lieating/Coolidg Return) ❑Other(e laitriiinder#21 Remarks)i
' n 16 e) ft
4.Date Well(s)Completed:�1—j� t
i�r WeuID# rll; ,�- is i!9 ft � Sc,_L 3
�I ft r Z3 f. �' S oIL
3-
Sa. eIl Location:
Facility/ Name, Q G Facility IIN//'i(,ifapplicable) ft Gc P !L
&ddress.Ciln and ZipI'+E ft fL
Per w a -7 Iltlt` 030
County Parcel Idatind cation No.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 :cerac2ti'D _
35 N 80 -
't of ed Well Contractor Date
6.Is(are)the well(s): erwanent or ❑Temporary��I� Si � �
-signing this f 1 hereby certify that the—11(s)was(were)constructed m accordance with
7.Is this a repair to an existing well: ❑Yes or o',!' P 4 NCAC 02C 01001 or 15A NCAC 02C.0200 WeU Construction standards and that a copy
1 this is a air, u out known well cons"cdon in ormadon and n the native o the o record b provided to the rveU owner
f rep f+ I" �P f
repair under 421 remarks section or on the back ofddsform. IIi
2 Site diagr.,An or additional well details:
�IIII S.For Geoprobe/DPT or Closed-Loop Geothermal Wells) Y u may use a back of this page to provide additional well construction info
ving the same ,.• ,
construction,only 1 GW-1 is needed. Indicate TOTAL NUMIBER of wells - ( 'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: ih
� (( 2 ,SUB AL I1�iSTRUCTIONS +
9.Total well depth below land surface: - /f ,111 UP
S bmit this -1 within 30'der s of well co letion
For muln'ple wells list aU depths ifdtfferent(example-3@200'and 2 '-00� I , I ,• Y top per the following:
p cuing: ( ) 2 a For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below to of i lion ing Unit,1617 MSC,Raleigh,NC 27699-1617
If xnter level is above easur�use"+" i I i ;
11.Borehole diameter 6° (io,) Z b:For In' ''on Wells:Copy to DWR,Underground Injection Control(IUC)
' gram,1636,MSC,Raleigh,I,NC 27699-1636
t
12.Well construction method:Air Drill �I• 2 `,For Watt ;Supply and Open-LoopGeothermal Return Wells:Copy to the
(Le.anger,rotary,cabl direct h e, irec pus .etc.) b° ea - en health d.- !mty epartntent of the county where installed
I'
FOR WATER SUPPLY WELLS ONLY: 2 ; For Wa :r .Ib,vredncing over 100,000 GPD:Copy to DWR,CCPCUA
- 7 P ' 't Pro 1 11 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) / Method of test: ;r
13b.Disinfection type. Sterilene Amount: An J_ �f
Form GW-1* North Carolina artmeat of Eavironmen Quality-DWI;iior of Water Resources Revised 6-6-20is
i