GW1-2023-01776_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: �!
1.Well'Contractor Information:
Ricky Corrih'er K.FROM I TO DESCRIPTION
Well Contractor Name
2464-A ` /� ft ft
NC Well Contractor Certification Number p
Frank A. Corriher& Sons Well Drilling, Inc. FROM To DIAMETER THICIQVESS MATERIAL
it ft-
Company Name p (/){�
2.well Construction Permit#: 3 ""-2 `� FROM /TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits P.UIC,County,State,Variance,etc.) +1 ft [G ft 6 1/8; in' SDR-21 PVC
it
3.Well Use(check well use): �ft 6 I sip 4Y
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESs MATERIAL
❑Agricultural` ❑/Itlnicrpal/Public it it ?in
❑Geothermal(Aeating(Cooling Supply) Residential Water Supply(single) ft ft in.
❑hidusttial/Commercial I ❑Residential Water Supply(shared) -
❑hfi ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 122 ft Bentonite Hole Plug
❑Monitoring ❑Recovery t it ft. _
r Injection Well: `,M ft
❑Aquifer Recharge ❑Groundwater Remediation -
_ _ e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
it ft� I
❑Experimental Technology PSubsidence Control tt ft
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❑Geothermal(Closed Loop) ❑Tracer -
FROM TO DES ON eolo hardness,soiYrock a size,etc)
❑Geothermal(Heatinpf Cooling Return)2 OOther(explain under#21 Remarks) O ft 3 d ft I'
4.Date Well(s)Completed:1 Well ID# Q ft- 9 ft lc
5a wev:I.ocatiDn: -fer+ee
r � J �` 1 Wit
Vt/G1/1 �a j+✓r�/ •I
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ftV ft.Facility/OwneerName /^� /��j - 1/�/7yacilityID#(ifapplicable) _ I
�/7 ��Li/+ �'�A v �F 1,3 7 ft ft
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ft.. ft '
Physics City,and Zip
o-� '9 o
�.;
count, Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees! _
(if well field,one Wong issuffrcient)'•, � �I g 22.Ce ' -lion• FEB 2-� 2023
1 35� o N 80
O -d3 - 0� w
6.Is(are)the well(s): ermanent or ❑Temporary Signature of ed Well Contractr I � ' Date
By signing this form,`hereby tern;fy!lhat the well(s)was(were)constructed in accordance with
7.Is this a,repair to an existing well: ❑Yes or o 1 SA NCAC 62C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
ff 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 1 GW-1-is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also:attach additional pages if necessary.
1.
wed: - 24.SUBMTTTAL INSTRUCTIONS
35
9.Total well depth below land surface: (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@100)
24a. For All Wells: Original,form to Division of Water Resources (DWR),
10.Static water level below top of casing: 1� (it) lnformation 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 Ito DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Air Drill �
12.Well construction method: 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 m producm over 100,699-000 GPD:Copy to DWlt CCPCUA
Air Permit Program,1611•MSC,Raleigh,NC 2716
13a.Yield(gpm) Method of test: 11
f �
13b.Disinfection type: Sterilene. Amount: CAS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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