GW1-2023-01255_Well Construction - GW1_20230127

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher -
mom ITO I DESCRIPTION
Well Contractor Name
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2464-A
NC Well Contractor Certification Number '�;S;fOT)�R ,�"S1�7�Gc�,• �nu1Qt�;�Q��eiis'gip- - ---
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO DIAMETER TlucxNEss MATERIAL
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Company Name 7
1YNERC11� i ........... eatteir
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) t1 // ft g �/it- 6 1/8 rn SDR-21 PVC
3.Well Use(check well use): 9'6 ft �3 n O ft. J'/B r.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ 'cipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fL
❑Industria/Commercial �^° �sidential Water Supply(shared) & ;
n ,
❑hTi atioII r' �. +~' t. y ells>100,000 GPD FROM TO MATI'sRIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSuppyWell:"- - n 0 't 22 ft Bentonite Hole Plug
❑Monitoring N1 9 i ZOZ3❑Recovery fL fL
Injection Well: ^!�S3 fL ft
F
❑Aquifer Recharge +'tt' �GroundwaterRemediation
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❑Aquifer Storage Ad Recovery ❑Salinity Barrier FROM TO MAT17RIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer u fl etacha+i rib al°sh"ee�s . ecesss
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION eo)or,hardness soiltrock e, size etc
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4.Date Well(s)Completed: , 1 U r Well ID# �� ft �� ft v d 5,7�Lp
5 Well Location: )-g' It. ?O ft SO pC�C
OACA'At'6 efayeal-5
Facility/Owner Name -V Facility
yIIDD#(if applicable) ft ft
si{,4z / � /f11/. 6!*oo Gl ft ft
Ph ysi I Address,City,and Zip ft.Z0 we rl I,20 O/<3I2/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce 'rcation-
35Q,;j ' L/6; N 80 D�� � - w
6.Is(are)the well(s): ermanent or ❑Tempora;.z
signature o ertified e 1 Contractor Date
Bv sign ing thisform,I hereby certify that the we was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1 SA NCAC 02C.0100 or 15A NCAC:02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe. of this record has been provided to the well owner.
repair under 411 remarks section or on the back of thisform.
23.Site diagram or additional well details: ,
S.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 (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
filled: GG� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: O/ (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: —+ (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6" (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount: rap
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018