GW1-2023-02900_Well Construction - GW1_20230418

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Ricky Corriher -
Well Contractor Name FROM TO DESCRIPTION
ft. ' `c"L
2464-A- G'
It. rt
NC Well Contractor Certification Number --
Frank A. Corriher& Sons Well Drilling, Inc. FROM ft TO ft DLAMME-UR in. TMCXNEss MATERIAL
Company Name -
2.Well Construction Permit#: y�
^FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) t1 ft ft 6 1/8 in SDR-21 PVC
3.Well Use(check well use): IC/ ft ft / - in. Q lv
Water Supply Well:
FROM TO DIAM
ETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural iid..t'l/P ft ft in.
❑Geothermal(Heating/Cooling Supply) al Water Supply(single) ft ft in.
❑IndustriallCommercial ❑Residential Water Supply(shared) t U -
FE01Aquifer
ation ❑Wells>100,000 GPD FROM TO MATES r�LA�E T METHOD&AMoiINT
ater Supply Well: O ft 22 tt Bentonite Hole Plug
d n itoring ❑Recovery rt ft.
l ion Well:
,� ft ft
Recharge ❑Groundwater Remediation
n ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
O ❑Aquifer Test _ ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer 'tro
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock sae,etc)
C1 m tffl ft
o� 4.Date Well(s)Completed: 1-3-00. Well ID# ft '00", �sL
5a.Well Location: }� I ft ift
t� ft t
O Facili /OwnerN /► Faci�lityID (if plicable) ft ft
✓✓ �� ' li' /1 t Tit/ ft ft 7
Ph ys' I Address,City,and Zip ft ft
)va S'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latpong is sufficient) 22.Cerlific 'on:
350'3 S��� N 80 CP r.3�)`` W �y _
6.Is(are)the well(s): BPermanent or ❑Temporary Signature of ed Well Contractor Date
fo fiy signing this form,I hereby 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 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has beenarovided to the well owner.
repair under#21 remarks section or on the back of thisform. 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'Se a Over'in Remarks Box).You may also attach additional pages if necessary.
drilled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Q� (ft)
For multiple wells list all depths if different(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),
10.Static water level below top of casing: (ft) Info
Ifwater level is above casing,use rmation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+"
11.Borehole diameter: 6° (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(JUC)
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
(ie.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,'00 GPD:Copy to DWR,CCPCUA
r f 11 r Permit Program 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Sterilene Amount:
Forma GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018