GW1-2023-01721_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD (GW-T) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher - --
FROM TO DESCRIPTION
Well Contractor Name fL "", � 4
VL
NC Well Contractor Certification Number -3 / -
Frank A. Corriher & Sons Well Drilling, Inc. FROM To DL4MECER TTUCENESS MArcursr.
fL
Company Name J
2.Well Construction Permit#: J v ./ O ! FROM To I DIAMETER THICKNESS MATERW,
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) +1 fL {,� ft- 6 1/8 in' SDR-21 PVC
3.Well Use(check well use): i 1vh yyft - — �� z�
Water Supply Well: FROM TO DIAMETER SLOT S[ZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) -
❑Irri ation ❑Wells> 100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O fL 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery iL [t
Infection Well: —
ft fL
❑Aquifer Recharge ❑Groundwater Remediation
\ ❑-Aquifer Storage and Recovery ❑Salinity Barrier FROM TO... MA ERtAL ENDIACEEMENT�HIETHOD
N ❑Aquifer Test ❑Stotmwater Drainage fL (t
❑Experimental Technology ❑Subsidence Control fL fL
❑Geothermal(Closed Loop) ❑Tracer "toME
❑Geotherm FROM TO DESCRPTIONmior,hardness,soillrock size,etc.)al(Heating/Cooling Return) ❑Other(explain under#21 Remarks) v tt v ft.
4.Date Well(s)Completed: 1 v Well ID# {,] fL ft. Z S T
5a.�Well Location: !, ;)ft. t — le
tL ft. —
G Facility/Own fL fL
er Name Facility ID#(if apPl c�b /� _
DOer �le kw/I �liS��/� j( fL fL �nL
e� Physical Address,City,and Zip
fL ft.
K�j>v�A G >L107'? _
Cotmty 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 ratio
3563 N 800 —oil/ i IF " W
-4 -23
6.Is(are)the well(s): *ermanent or ❑Temporary Signature of rtified Well Contractor Date
By signing this form,I herebv certifv that the)wll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes oi. �./ 1 SA NCAC 02C-0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Lf this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).YDu may also attach additional pages if necessary.
filled' / 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / y-� (ft.)
For multiple wells list all depths ifdiffferent(example-3@200'and 2 100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing,use"+"Static water level below top of casing: (ft.)
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
LJ '
11.Borehole diameter: 61, (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12-Well construction method: „I r Drill
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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 GP D: Copy to DWR,CCPCUA
13a.Yield(gpm) —ISO Method of test:AI r
Permit Program,1611 MSC,Ra1eil;h,NC 27699-161 I
1 r�
13b.Disinfection type: Ste rilene Amount: �CY- CLt �
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resouses Revised 6-6-2018