GW1-2022-08950_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -
I.Well Contractor Information: , �. �`'
Ricky Corriher FZ C,E z.F - - -
FROM TO aEscl:>pnoN
Well Contractor Name SEP 1 G 2022 .
2464-A %
u i1
NC Well Contractor Certification Number
Frank A. Coniher&Sons Well Drilling, Inc. oM nlAi -rrrr THItRQQESS ivlArEiuAr
ft ft. f I in.
Company Name � �
2.Well Construction Permit#: O(/V-1/ FROM TO DL11V>ETER TI�CIflVFSS MATEEWL
List all applicable well construction permits(Le_UIG County,State,Yarianee,etc) +1 ft 6 1%8 i'° SDR-21 PVC
3.Well Use(check well use): ft
Water Supply Well: FROM TO DLOEETE SLOTs1zE TIIICSNFSS MATERIAL
OAgricultural X
ip-M lic ft ft❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft. in
❑IndustriaUCommercial ❑Residential Water Supply(shared)
❑hfi ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMYLACEMEN17MMOD&AMOaNT
Non-Water Supply Well: 0 n' 22 ft Bentonite Hole Plug
❑Monitoring ❑Recovery ft %
Injection Wen: ft ft
OAquifie1 Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier xROMfL To fL MATERIAL NXMOD
OAgmifer Test ❑Stormwater Drainage
OExperimenfal Technology ❑Subsidence Control K
❑Geothermal(Closed Loop) []Tracer
FROM To DESCRIPTION eolor sofilrock . s�ete1
❑Geothermal(Fleating/Cooling Return) ❑Other(explain under#21 Remarks) ft
4.Date Well(s)Completed: gr—�4 e11 ID# ft ft i
52.Well Location: f
ft. ft
Fa/ei�lity/lOwne Name Facility (if applicable), 9
Facility
p n M
' ft ft
Pbys� Address,City,and Zip
Co ty, Parcel Identification No.(PEN) I'
5b.Latitude and longitude in degreeslminutestseconds or decimal degrees:
(if well field,one ladlong is sufficient) 80 22.C on:
N (�/ ��' �� W
6.Is(are)the well(s): 6Oermanent or ❑Temporary Si of Well Contractor Date
By signing this form,I hereby certtfy 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.0100 Well Construction Standards and that a copv
1 this is a repair,fiA out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 rmarks section or on the back of thisform.
23.Site diagram or additional well details:
8-For GeoprobeMPT 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'm Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: G� (ft)
For multiple wells Ust all depths if different(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the fonowing:
10.Static water level below top of casing: 24a. For All Wells: Original i form to Division of Water Resources (DWR),
( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+'
6" 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
11.Borehole diameter. Cm-) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r Drill 24c.For Water Supply and O en--Loop Geothermal Return Wells:Copy to the
(i.e.augc,rotary,cable,direct push,eta) county environmental health department of the county where fni ed
FOR WATER SUPPLY WEW ONLY: 24d-For Water Wells prods cing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) � ' n Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
d-
I
13b.Disinfection type: Sterilene Am..t-. C 1
Form f3W-1 North Carolina Department of Environmental Quality-Division of Water Reso r es Revised 6-6-2o 18