GW1-2022-09546_Well Construction - GW1_20221014

WELL CONSTRUCTION RECORD(GW 1) S For Internal Use only:
1.Well Contractor Information:
Ricky Corriher -
FROM TO.. DESCRrP'IION
2
Well Contractor Name '20 ° I
2464-A M Ln j
,NC Well Contactor Certification Number —
Frank A. Coniher& Sons Well Drilling, Inc. °M TO D'"M>r>R 'ffi
ft. ft I � in
Company Name
FROM TO DLNWIM -7MOCNESS MATERIAL
2.Well Construction Permit#:
Litt all applicable well construction permits(Le.UIC,County State,variance,eta) +1 ft fL 6 1/8'' 1a' SDR-21 PVC
3.Well Use(checkwell use): s 1p 2� Q`- u
Water Supply Well: FROM -1 70 ZPM4ITERIL
SLOTSIZE THICKNESS. MATERIAL
❑Agiicultutal ❑ al/Public ft. &❑Geothermal(Heating(Cooling Supply) tial Water Supply(single), ft. ft❑lndustrial/Commemial ❑Residential Water Supply(shared)
❑lrri on ❑Wells>100,000GPD FROM TO EMPLACEMP.NTMErHOD&AMOUNT
rNon-Water Supply Well: O 22 Bentonite Hole Plug
❑Monitoring ❑Recovery
Injection Well: it ft.
❑Aq�Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMEgT METHOD
❑Aquifer Test• ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft j
❑Geothermal(Closed Loop) ❑Tracer
V dGeothe®al(Heating/Cooling Return) ❑Other( plain under#21 Remarks) FROM TO DESCRD'770N(Bolo,lucdnev,sonhoek ace fie)
6 tc R
4.Date Well(s)Completed: Well ID# (� �s
Sa.Well Location: Y,1 ft.
Facility/OvmerName' IJ,F ( plicable)g, 6 M tt
ft. ft. ZGZZ
P A�''City,and Zip ( ft. � )rill
Gi 1A -
county Parcel Identification No.(PIN)
56 Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lla/long is sufficient) j !t 22.C;77: ` y '35D��S(l"���� Div 80�,— 7.� '�� W � � �`'�
/ Si of Well Co r S Date
6.Is(are)the well(s): hPermaaeat or ❑Temporary � r
By signing dwform,I hereby certify that the wells)was(were)constructed n accordance with
7.Is this a repair to an existing well: , ❑Yes or o 15A NCAC 02C.0100 or 15A NC 4C 02C.0200 Well Canstrucdon Standards and that a copy
If d&is a repair,fall out(mown well cmwmcddn information and explain the nature of the ojthis record has been provided to the well owner
rgwr under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You taay use the back of this page to provide additional well construction info
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells ( 'See Over'in Remadcs Box).You may also attach additional pages if necessary.
dlilled 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below Land surface: . [J' ( ) Submit this GW-1 within 30 days of well completion per the following:
For mrrltrple xvJls list all depths if different(example-3Q200'and 2Qa 100�
24a. For All Wells: Original!'form to Division of Water Resources,(DWR),
10.Static water level below top of casing: y (ft) formation processing Unit,16'17,MSC,Raleigh,NC 27699-1617
if water level is above casing,use
6" 24b.For Injection Wells:Copy to.DWR,Underground Injection Control(IUC)
11.Borehole diameter: Cm) Program,1636 MSC,Raleigh,NC'27699-1636
12-Well construction method:AI r Drill 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i a anger,rotary,cable,direct push etc.) county environmental health department of the county where installed
i •
[13a.
WATER SUPPLY WELLS ONLY: 24d.For Water Wells Water Wells produu ever 100,000 GPD100,000 GPD:Copy to DWR,CCPCUA
Yield(gpm) 19 Methodoftest:AIrPermit Program,1611 MSC,Raleigh,NC 27699-1611
Disinfection type: Sterilene Amount-
Form ow-1 North Carolina Department of Envirotmiental Quality-'Division of Water Resources Revised&&2018