GW1-2022-01211_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Cordher
FROM TO DESCRIMON
Well Contractor Name n ft. ft. 3
2464-A ` ft. ft.
NC Well Contractor Certification Number - -
Frank A. Corriher&Sons Well Drilling, Inc. FROM To DIAMETER ;SDR-21k
NESS MATERIAL
ft. ft. in.
Company Name `�
2.Well Construction Permit#: 1rJ /F�/_ (JJ� V1� FROM TO DIAMETER NM MATERIAL
List all applicable well construction permits fl.e.U1C,County,State,variance,etc.) +/1 fL ft. 6 1/8 �'"n PVC
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER. SLOT SIZE THIC[INFSS MATERIAL
❑Agricultural ❑ iclpaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) 1 esidential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) - -
01rri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft- 22 fL Bentoriite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft, ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERL►L EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21,Remarks) FROM TO DESCRn7To color Hess soilirock mm vain shr etc
pp�-1" O ft Q ft
4.Date Well(s)Completed:/ �Well ID# qc) ft. .f-D ft. s'Q
5a.Well Location: 5-0 ft. ft. .5 & C-
Facility/OwnW41'ern/Name ,per // /�� /Fa/glli{tj�JD/J(if applic/a/yle) ft ft �s
P1 l..!/ J/�S /C/ c/ r z.+ SGII• ft. ft.
Phys' Address,City,and Zip / ft.
0 Wa� 1� J�0 �uN�
County Parcel Identification No.(PIN) ' "
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �I
(if well field,one lat/long is sufficient) 22.Certification:
35CS/ N 800 33 W
6.Is(are)the well(s): ermanent or ❑Temporary Signanrrc of ell Contractor Date
By signing this form,1 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 NCAC 02C.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 well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l t7 -(ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3()a 200'and 2@100�
10.Static water level below top of casing: 30 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwarer level is above casing,use"+"
11.Borehole diameter: 6" (in,) 24b.For In eection Wells:Copy to DWR,Underground Injection Control(RUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r D rl 11 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 producintrloyer 100,000 GPD:Copy to DWR CCPCUA
13a.Yield(gpm) 30 Method of test:
AI r Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterllene Amount: Q Ca S
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource Revised 6-6-2019