GW1-2022-08949_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD (GW-I) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher ' F
V,
Well Contractor Name FROM TO DESCRn'TiON
2464-A SEP 1 �'2022 it �s n ,
% ft I; 1
NC Well Contractor Certification Number e - ! -
-. �n1'UI"i'�91u7.✓:l ��''i LbY.S` :���1 �
Frank A. Corriher&Sons Well Drilling, l'nrr:� FROM TO D � Tffis mnTElnnL
ft ft in.
Company Name' �j,
2.Well Construction Permit#: -/_f�J 17 v FROM To DUMEM MCNIMS MATERAL
List all applicable well construction permits r.e. IC,County,State,Yariance,etc.) t1fL I O ft 16 l i8 in SDR-21 PVC
3.Well Use(check well use): ft
f
Water Supply Well: FROM TO. DIAMETER SLOTSIZE MCKNFSS MATERIAL
❑Agriculhual ❑ cipal/Public ft ft in
,
❑Geothermal(Heating/Cooliog Supply) esidential Water Supply(single) it it in
❑IndustriaUCommercial ❑Residential Water Supply(shared) ` f
❑Irri ation -., ❑Wells>100,000 GPD FROM TO I MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft 22 ft. 13entonite Hole Plug
❑Monitoring ❑Recovery _ ft ft
Injection Well:
it ft
❑Aquifer Recharge ❑Groundwater Remediation
_ .
-OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MA'S ERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft tt
❑Geothermal(Closed Loop) ❑Tracer ' L ... ....
13Geoth FROM TO DESCREMON- sine,etc,'
(Heating/Cooling Return) Other(explain udder#21 Remarks) color h soStrock!
ft
4.Date Well(s)Completed:ll /' Well ID# Lf Z_iti I�
L
Sa ll Location: J ft aL$
ft ft r
Facility/Owner Name Facility ID#,(if a Ali le ft ft I
JI-~
Physical Address,City,and Zip R ft
C�unty Parcel Identification No.(PIN).
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oae ng'�ufficient) /
35 : ' N'80 0 � —' 17 i 22.c j tn:
_3
W ! - `
6.ls(are)the well(s): krmanent or []Temporary Signat6re of CedMed Well Contractor Date
By signing this form,1 herebv certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well ❑Yes or 1 SA NCAC 02C_0100 on ISA NCAC 02C.0200 Wa Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the wwa owner_
Fepair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
8.For C:eoprobe/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: ' I ,
1�� 24.SUBMITTAL INSTRUCTIONS
9.Total well 6
depth below land surface: ( )ft i
For multiple wells list all depths if d fferent(example-3Q200'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top'_f casing:, 0 (ft) 24a. For All Wells: Original Iform to Division of Water Resources (DWR),
Ifwater level is above casing,use'W Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter- 61# (in-) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill - {
'(i_c.auger,rotary,cable,direct push,etc_) 24c.For Water Supply and OpenL 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 producine:over 100 000 GPD'Co to D
V Air Permrt Program,1611 MSC,Ral4ergh,NC 27699-1611 Copy �'CCPCUA
13a.Yield(gpm) Method of test:
13b.Disinfection type: Sterilene Amount:
Form GW-1
North Cazolina-Department of Environmental Quality-Division of Water Resourices Revised 6-6-2018