GW1-2022-00918_Well Construction - GW1_20220107

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: is
Ricky Corriher
FROM ITO IDSSCRII'1I0N
Well Cont a or Name /0.01ti
2464-A it. ft
NC Well Contractor certification Number
Frank A. Coniher& Sons Well Drilling, Inc. 6oM 70 DIAMa`I'ER 7mom
ft. tti in
Company Name n/a
70 2.Well Construction Permit#• OS/`Jd ` FROM TO DIAbIETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC County,Srate,Variance,etc.) }� ft ft- 6 1/8 'o- SDR-21 PVC
(� 3.Well Use(check well use): `3 fL 3 it Q,
'V Water Supply Well: FROM TO DIAMETER SLOT slit, THICKNESS MATERIAL
❑ tural ❑ crpa]/Public ffi ft.
❑Geothemtal(Heating(Coohng Supply) 'dential Water Supply(single) ft. fL in.
❑lndustrial(Commerciai ❑Residential Water Supply(shared)
OhTigatiou ❑Wells>100,000 GPD FROM To MATE " EMPLACEMENT METHOD&AMoUNf
© Non-Water Supply well: 0 fL 22 fL Bentonite Hole Plug
\ ❑Monitoring ORecovery ft. it.
Injection Well: ft. fL
Opquifer Recharge ❑Groundwater Remediation _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
�\ ❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control iz
❑Geodamal(Closed Loop) ❑Tracer
OGeothermal(Heatin Cooling.Retum). ❑Other(explain under#21 Remarks) FROM1 TO D Ox color,aridness,sorlhoek - eteJ
® 10 ft ft-
4.Date Well(s)Completed: Well ID# ft 3 tL )fDf`�/� Awl?—
R �tj�� � .Y�?j , rnr
5a Well Location:
mo-1 kit� D&L"ram l� 11\elo� & M
Flac/ilittylow� aint Facili #(ifapplicab ft. ft.
ft. fL
Physical Address,City,and t ft ft.
p , ` - 1
County Pz=f Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fall,one belong is sufficient) 22.C cation:
35,0, N 80 0�3 9 '5 w
6.Ware)the well(s): Wr manent or ❑Temporary si of ed ell Contractor Date
IN signing this form,I herebv cerhfv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 15A NCAC 01C.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 of the of this record has been provided to the%yell owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For GeoprobelDPT 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 ( 'See Ovee in Remarh Box)_You may also attach additional pages if necessary.
wed' 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: (D') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
St 24a. For All Wells: Original'form to Division of Water Resources (DWR),
10.Static water level below top of casing:
10. r level is above casing,use op � (L) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfw11.Borehole diameter:6" (�) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill
(Le.su®er,rotary,cable,direct push etc) county
For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Cop
y to DWR,CCPCUA
Yield Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
(gpm) Method of test-Air
13b.Disinfection type: Sterilene Amount~ 3 J
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018