GW1-2022-10211_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Ricky Corriher RECEa/E D --
Well Contractor Name N O V 1 1 1 1 2022 FROM ft To ft DESCRIPTION
Una
2464-A � l�t1 l
o�NCN0
NC Well Contractor Certification Ntmibe) �� procawwv -_ 3- L CL —
Frank A. Cordher& Sons Well Drilling, Inc. EOM TO DIA�.M IMCXMS MATERIAL
ft fc 6 j ;n
Company Name 3 75570
2.Well Constriction Permit#: J FROM TO I DIAMETER T'ffiCIQiFSS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) t 1 ft' t�� ft- 6 1/8 in' SDR-21 PVC3.Well Use(check well use): �Q ft /� fL b q
Water Supply Well: FROM TO DIAMETER SLOT SEM THICKNESS 7AMOUMNT
❑Agricultural ❑M cipal/Public ft fL in.
❑Geothermal(Heating(Cooling Supply) esidential Water Supply(single) % ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Ini lion ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHO
Non-Water Supply Well: 0 It 22 ft Bentonite Hole Plug
❑_Monitoring ❑Recovery ft M
Injection Well:
[t ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO WIN ntAiExirAL EMPLAcstv>ENThMMOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer
FROM TO DES ON color sow ete.
❑Geotherm l eating/Cooling Return) ❑Other(e lain under#21 Remarks) ^ .7 C1 ft
�Q V J D
4.Date Well(s)Completed: to,- Well ID# tt
5 Well Location:
tt [t ' !LC `�' 1�►'L�
�e�-�l-, ft- It
Facility 1D#(if applicable)
ft ft
ft ft.
Phyei Address.City,and Zip X ,�.,��� ft. [t
D7y'c� 0, J`
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C catio
35 N 80 W
6.h(are)the well(s): tg'r.Q—nent or ❑Temporary Signature of ed Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a copy
If this a 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#11 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: 102 (ft.)
For multiple wells list alldepths if different(example-3(a)200'and 1Qa 100� Submit this GW-1 within 30 days of well completion per the following:
p mg: 0 (fL) 249. For All Wells: Original40tm to Division of Water Resources (DWR),
10. ter le water level below to of cos' Information ProcessingUnit,1617!MSC,Raleigh,NC 27699-1617
If water level is above casing,use..+', I �•
11.Borehole diameter• 6" (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Drill
24c.For Water Supply and Open-Loop Geothermal Return Wells'Copy to the
(Le-su®er,rotary,cable direct push etc-) county environmental health department of the county where installed
FOR WATER SUPPLY LLS ONLY: 24d For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raletgh,NC 27699-1611
13a.Yield(gpm) Method of test Air
13b.Disinfection type: cterilene Amount: �C�Ci
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018