GW1-2022-10214_Well Construction - GW1_20221111

.WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: R E C EN E
Ricky Corriher Well Contractor Name N 0 V 11 2
TO DESCRIPTION
2464-A � ft.
It�pnaluon Pr c-310" g rdt sr it.
NC Well Connector Certification Number (}WOMOG -
Frank A. Corriher& Sons Well Drilling, Inc. °M I TMO DIAMETER IMCKNESS MATERIAL.—
ft. ! inOWN- .
Company Name ,.:,;, � Q�® _ -- _ �.
2.Well Construction Permit#: /E�/� FttOM ro DL�METER f7PIN DcMIX I M MATERI er
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) +� % /!3 R 6 /$ in SDR-21 PVC
3.Well Use(check well use): 3 it ° t:/
Water Supply Well: FROM TO DLAMRTER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M ipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft fL in.
❑Industrial/Commeroial ❑Residential Water Supply(shared)
0hrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
rOGeothenmal
er Supply Well: 0 IL 22 ft Bentonite Hole Plug
ring ❑Recovery ft ft
well:
tt ft
r Recharge ❑Groundwater Remediation
r Storage and Recovery ❑Salinity Barrier ZEROM
To nffAii Rrnl EMPLACEMENT METHOD
r Test ❑Stormwater Drainage (tr+P*+tal Technology ❑Subsidence Control ftmtal(Closed Loop) ❑Tracer
TO DES ON color,hardness,soWrock etc.
v mal eating/Cooling Return) ❑Other(explain under#21 Remarks) O - Y
C 4.Date Well(s)Completed:13 a Well ID# ft —57Zt t S
Sa.Well Loca"on: �" [t �� tt Sp �t—/-<—.
/-r a LA G k to�6-n t aEn 3 ✓'Qt /'L
Facility/Owner Name Facility ID#(if applicable)
fL
[� �j R. ft
PhysicalZip
/S `2ZJ
f� County Parcel Identification No.(PIN)
v 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat bong is sufficient) r// 22.C ratio
35 6 N 80p 3o `" w —Z- �r� ,
6.Is(are)the well(s): e an rmeut or ❑Tempora;�-�
Signature of ed Well Contractor Date
!ty signing this form,I hereby certify that the wvll(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or /SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a capv
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 remade section or on the back of thisform. 23.Site diagram or additional well details'
S.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.
Willed' e 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (f Submit this GW-1 within 30 days of well completion r the folio For muln'ple w�eUs list all depths if different(example-3Q200'and 2Qa l001 _ Y p per wing:
�® 24a. For All Wells: Originallform to Division of Water Resources (DWR),
f Static water level below top of casing: (fh) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing;use..+•. g F�.
11.Borehole diameter: 6° (in-) 24b.For Injection Wells:Copy to DWR,Underground injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(ie Well construction method,Air D ri I I 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 producing over 100 000 GPD:Copy to DWR,CCPCUA
13a.Yield Wirt) Q Method of test:Air Petmtt Program,1611 MSC,Raleigh,NC 27699-1611
tn �J d
13b.Disinfection type: Sterilene Amount: C
`i
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018