GW1--07327_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: {
I
1.Well Contractor Information:
Ricky Corriher- e:
"•':1'4€: •EH s,+ii:: °si:i3>:#?r'` it% •s><� :;°;: '::5'sii���iii�s�:i?:;%;>>:;.;:i�F- -
Well Contractor Name FROM TO DESCRIPTION
136�. 70 0•
2464-A ft. ft.
NC Well Contractor Certification Number . <•
.15.(?.UTERG;AS�G.(far�mulh cased:Srells).QIt);IlVE11;:i(11'-�•ap lic5lile) :...... :........
. Frank A. Corriher & Sons Well Drilling, Inc. FROM s TO DIAMETER THICKNESS I MATERIAL
ft ft in
Company Name 0 gq
/ ., ...
„ 6.;INNERASTG OR.TI3BING(gt ntNermal'clo3ed,IRAp) ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(!!C,County,Slate, Variance,etc.) +1 ft. 1Ohft. 6 1/8 '°• SDR-211 PVC '
3.Well Use(check well use) 0 /(' 2 3� c)11J
: 1.
/ -
Water Supply;Well: ;,:,17>. _ N._.
FROM TO \ DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ micipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ' Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water SuPP 1'(shared)
aft.,ItOitt
qliViiiiiglininNinglMiiiiiiiiiiMMiiitiiiiiiiiiiiiitiggiiiiiiiiiiiiiiiiiiiWiiiigigiiiiilligitiiiiiiiii,
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 22 ft. Bentonite Hole Plug
fr) ❑Monitoring ❑Recovery ft. ft.
Injection Well: ft ft
S1) OAquifer Recharge ❑Groundwater Remediation I
. ..19,.SANDIGRAVlLPACK(r£.applicable) -.,.. .... ..,-. .
❑Aquifer Storage and Recovery ❑Salinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft. ;
❑Experimental Technology ❑Subsidence Control - ft. ft. -
❑Geothermal(Closed Loop) ❑Tracer . :::30i:DRFIiLi19G3'O•.G:;(attacliadeitiorial-stiee4S:af:necessar3J:::,:::.:::::.::.:::.::::::.::.:.:::.:::::.:
C�--L\�1 0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION e1nr,hardness,sn khpe,grain s re,etc.)
(� D ft. S ft. jQ n ,l
64.Date Well(s)Completed: I v —2ij�( We1I ID# ,. +Oft. ft. I'5 c) (� I'�,t�-��
Z 5 ell Location: /•() Z 1 �-s [ C.t`e �^ y(.t -
,��•* � 4 a kntc De'Prife6 cYtW6 0el/04/1 q ft. ft. - -
Facility/DwncrName Daily ID#••£applicable) tc,C) ft. ft. t.•'s�-.r' i;` 7
qo old be,,h1y bird .6hme, -.4NOV1 7023_
Physica Address,City,and Zip ft, ft. '
i
6 'ti
14
//a rnJ 1�� YYY - T••I.J�e
/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .
(dwell 800 field, lat/long is sufficient) / //
3522.Certifi lion'
N � `,- sal/ `9p n ;�� /0
6.1s(are)the well(s): ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7:Is'this a repair to an existing well: ❑Yes •or & o . 15A NCACO2C.0100-or 1:A WAG'02C.0'00.tvdl Cunstrnction Standards and that a copy
' If this is-a repair,fill our 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 nr on the hack of this fawn. I
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 OW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. i� 35 (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-J 2O0•and 2(4u100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �/ (ft.) Information Processing Unit,16171MSC,Raleigh,NC 27699-1617
!f water level is above casing,use"+" ' l
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:Alr Drill
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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
l
13a.Yield(gpm) n Air Permit Program,1611 MSC,Raleigh;NC 27699-1611
CJ Method of test:
13b.Disinfection type; Sterilene Amount: � Sri-�J cr +
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources 'Revise d 6-6-20111