GW1--03142_Well Construction - GW1_20230505

WELL CONSTRUCTION RECORD(GWA) For Internal Use Only:
I.Well Contractor Information:
Ricky Corriher -
FROM TO DESCRIPTION
Well Contractor Name
2464-A- ft
NC Wen-Connacte Certification Number
Frank A. Corriher&Sons Well Drilling, Inc. FROM TO
Company Name O Q C1 2
r L J FROM TO DIAh1ErER TffiCI 2�mSS MATERL9L
2.Wen construction Permit#: +1 ft. ft 61/8 in SDR-21 PVC
list all applicable Nell construction permits CLe.UIC,County,State,Variance,etc.)
3.Well Use(check well use): OZ ` S� <9
Water Supply Well: FROM TO I DtAtirF-rrtR SLOTSM TFIICIQESS MATERIAL
❑A.gricultural ❑ cipal/Public fti in'
❑Geothemml(Heating/Cooling Supply) idential Water Supply(single) ft fL in.
❑lndustria commercial OResidential Water Supply(shared).
r10--�1Aquifr
❑Wells>100,000 GPD FROM TO M^TL EMPLACEMENT MEraon AMouNT
r Supply well: O tt 22 fz Bentonite Hole Plug
y ng ❑Recovery ft ft.
well: fz n
gage ❑Groundwater Remediation —
QOAquitr Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EmMAC dlfa TW ETHOD
OAquifer Test
❑Stormwater Drainage ft it.
pFaperimeafalTechnology ❑Subsidence Control fz it
OGeothertnal(Closed Loop) OTracer
FROM TO DESCRIPTION q*r,hardness.smVre&
OGeothermal
(Iieating/Cooling Return) OOther(explain under#21 Remarks) J �
c 4.Date Well(s)Completed- ~' _ WeI1 EW LS a fz 23
5a.well lion: ft. fL
a � a ft Yo
Facility/ownerT
L II Fae tyID#(ifapplicabley
113 �� gO�S , r/1 ,C� C- a 63 w ye. ft. ft MAY " �
�J
Pam`Address,City.and Zip
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(?well field,one1aUiong is suffiJ rent) p C lion: -
oo
Signarae of wen Contractor Date .
6.Ware)the well(s): err.—ent or OTemporary
By signing this form,I herebv certifv that the wYll(sJ was(were)constructed in accordance with
7.Is this a repair to sn eXWing well: ❑Yes or o 15A NCAC 02C.0100 or 15A NCAC 02C.0260 Well Construction Standards and that a copv
1f this is a repair,fill out!mown well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 rernarb'souion or on the bath of this form. Z3,Site diagram or additional well details:
e You may use the back of this page to provide additional well construction info
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the sam
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells
drilled: I 24-SUBMIT'TAL INSTRUCTIONS
9-Total well depth below land surface: r ( ) Submit this GW-1 within 30 days of well completion per the following:
For multiple welk list all depths if different(example-3@200'and 2@10a�
24a. For All Wells: Original foram to Division of Water Resources (DWR),
10.Static water level below top of casing: ( ) Information Processing Unit 1617 MSC,Raleigh,NC 27699-1617
!f rater level is above casing;use"+•.
6° 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter. (m) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:/'!!r D rl I I 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 producinz over 100,000 GPD:Copy to DWR,CCPCUA
13a-Yield(gpm) Method of test
Ai r Permit Program,1611 MSC,Raleigh,NC,27699-1611
13b.1)isinfectiontype Sterllene Amount; CO „
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resburces Revised 6b2018