GW1-2023-02947_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Con iher
FROM TO DFSCEIF'IION
WellContta=Name ft 1,? i 3
2464 A- 1- S-,'
NC Well'Comia=CeitificationNumber
Frank X Corriher&Sons Well Drilling, Inc. °M TO nr�M MA ,L
IAL
1.Well Construction Permit# � FROM DIAMSr� � �
L&t all appGmb&w-U consruuion permFtr(ie VIC,C—V,stares i�—ce,err) +1 ', tt 'a SDR-21 PVC
3.Well Use(check well use):
Water Supply Welk FROM TOOAgr DIAI•fEIER SLOT STI.EE TSICI S T AL
a[03Zjnd&LqUjajfC;ommercia1
� ❑ cipaUPublic %
mal(Heating/Cooling Supply) idential Water Supply(single) ft ft. in.
❑Residential water'Snpply(shared)n ❑Wells>100,000 GPD FROM TO MATERIAL gMPLAC8M1 Nr/4sTnoD 1tr AMOiTNT
Non Water supply WeD 0 22 tt Bentonite Hole Plug
❑Monitoring ❑Recovery ft.
Injection Well: M fL
0A4rifer age ❑Groundwater Remediation -and Recovery ❑Salinity Barrier FROM TO MATERIAL UaLACEMNTNMMOD
i�Agnifer Test
❑Stormwates Drainage ft
❑ExpedmentalTechnology ❑Subsidence Control 1
❑Geothemlal(Closed Loop) ❑Try FROM To oN eoltr, `�1BCttym gnom MD,"`)
❑Geoth®al(Heating/Coolmg Return) ❑Other(explain under#21 Remarks) O ft. ft /b rti�'tJ
4.Date We11(s)Completed: Well M#
Sa.Well Location: fctt. VIE
fa ft L
Faci/li�ty/O.varr N/mpe a Facility ID#cif licable) ,
c+5��ra i(�'lt.. �..eG✓ C�SCt�� fb r t` tn3s3nr'.-*axiacl i�r,�; �. i
ft. D1'lQJ3t?G
P .Addxe.r,, . dZip -
0wn
County Parcel Identification No.(PIN)
5b.Labtade and longitude m degrees/minmes/seconds or decimal degrees:
(if weu field,ona builong is sufficient) / t/ 22 C do
Sip�anae of Wen Contractor. Date
6_Is(are)the we11(s): era><went or ❑Temporary
U}signing this form Lhoebv certify that the xeU(s)was(were)constnrctrd ut accordance xidr
15A NCAC 02C.0100 or 15A NCAC 02C.0260 WeU Construction Standards and that a copy
7.Is this a repair to an existing bye]( ❑Yes or o
Lfdds is a repair,fiU out Imowm weU construction information and ezplerr the nature of*e
of this record has been provided to the well owner
repair corder#21 remarkr soon or on the back of this form. 73.Site diagram or additional well details:
e You may use the back of this page to provide additional well construction info
8_For Geoprobe/DPT or Closed-Loop Geothermal Wells having the sam
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach acrtiatrel pages if necessary
ry
duilled � 24.SUBMTfTAL INSTRUCTIONS
!_Total well depth below land surface: (ffi) Submit this GW-1 within 30 days of well completion per the following:
For multiple wills fist aU depths fjd+ffero (e=nple-3Qa 200-and 2@100')
(ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below.top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ffwcterlevelisabove casing use"+
w 24b.For Infection Wells:Copy to DWR,Underground Injection Coritrol(IUC)
1L Borehole diameter:6 Cm) 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,and,totmy,cab)e,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 10Q000 GPD:Copy to DWR,CCPCUA
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a_Yield(gpm) �o Method of test
13b.Disinfection type_Sterilene Amount: l�.S
Form Gw-1 North Carolina Department of Envitonmeatal Quality-Division of water Resources Revised 6-6-2018