_Well Construction - GW1_20230320 (25)

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher -- = -
Well Contractor Na FROM TO DESCRIPTION
Nam
rt y t D
2464-A ft. ft
NC Well Contractor Certification Number --- -
Frank A. Corriher& Sons Well Drilling, Inc. FROM TO niAMETER THICKNESS MATERIAL
ft fL in
Company Name 2.Well Construction Permit#:3i//�/
-�O I FROM TO �DIptV1ETE[t -MCKNESS MATERUL
List all applicable well construction permits(.e.UIC,County,State,Kinance,etc.) +1 IL 10/ft. 6 1/8 in SDR-21 PVC
3.Well Use(check well use): p tt 0 3
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agrieultural ❑ cipal/Public it it in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft % in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT MEMOD&AMOUNT
Non-Water Supply Well: 0 it 22 fL Bentonite Hole Plug
❑Monitoring ❑Recovery it IL_
Injection Well- ft [t
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENYMETHOD
❑Aquifer Test ❑Stormwater Drainage
it ft.
❑Experimental Technology ❑Subsidence Control fL ft
\ ❑Geothermal(Closed Loop) ❑Tracer
❑Geothermal eating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,safllrock type,grain size,eta
0
4.Date Well(s)Completed:�� »Well # p ft O ft- $C' ' i
U Sa.Well Location: 9'0 tt 0-3 ft S R_
y a /<�/�sS n GC�/�oz U3 t` 2(�'t�
� Faci/lity/OwnerN� � � Facility ID#(if applicable)
fL %
tt ft.
Physical Address,City,and ft. ft. _
Fb�,a z o rygo 10
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ctr"0i';'.�i
(if well field,one lattlong is sufficient) 22.C catio
350,'3�/ / ,N 80o (13' '- 1 W
6.h(are)the well(s): ermanent or ❑Temporary Signature of ed Well Contactor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or O;No 1 SA NCAC 02C.0100 or]SA NCAC 02C.0100 Well Construction Standards and that a copy:
If this is a repair,fill out/mown well construction information and explain the nature of the of this record has been provided to the well owner
repair under#21 remarks section or on the back ofthis 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: . of (& -
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
ljtvater level is above casing;use
f Static weber level below top of casing: (� (ft hrformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter: 6" (in) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Air D ri I I Program,1636 MSC,Raleigh,NC 27699-1636
(Le Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
` Permit Program 1611 MSC,Raleigh,NC 20 0 -1611
13a.Yield(gpm) J O Method of test:Air
l
13b.Disinfection type: Sterilene Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-2018