GW1--03327_Well Construction - GW1_20230512

WELL CONSTRUTCTION RECORD GW-1
For Intelnai Use o»ly:
L Well Contractor Information:
Ricky Corriher _J
Well Cow Name FROM To
2464-A a ft.
DEscRII•rION
o fL
NC Well Conhacior Certification Number ft. rL
Frank A. Corriher& Sons Well Drilling, Inc, FROM TO DIAiw rFa -
Company Name ft. T� MpTI RIAI
� � ft. UL
2.Well Consh action Permit >.#:_ 9�`/ 1� F1toM To
Litt aU applicable well construction permits(ie.UIC.County D M T� MATIItIAL stare,Varian etc) +1 rL fL 6 1 1/8 1°'
3.well Use(check wen Use): fL SDR-21 PVC
fL in
Water Supply Well:
❑Agriculhnal pM rpal/Prrblic mom TO DL�MgTER sLOTSTlE THICKNffiS MATERIAL
❑Geothermal(Heating/Coolin Supply) ft
g uPP Y) Residential Water Supply(single) UL
pindusaial/Commernial ft. ft. in.
❑Residential Water Supply(shared)
❑Turf on O Wells>100,000 GPD FROM TO
Non-Water N apply Well: MAT�AL �►r�tl METDOD&AMotrxr
❑Monitoring pRecove 0 22 Bentonite Hole Plug
Injection Well, ry n iti
❑AQurrfer Recharge ❑Groundwater Remediation '
❑A iiibr Storage and Recovery ❑Salinity Barrier FROM -TO
`
❑Aquifer Test ❑StormwaterDraina a ft. rrrMeraoD
$ fL
pFxpeaimentalTechnology p Subsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer
pGeothemral(Heating/Cooling Retum) pother(explain-under#21 Remarks) FROM TO D ON ruudneq
�7+ »eec
4.Date Well(s)Completed b' w-n ft.
a
5a.Well Location:
ft. g, J
rYti-- anl t e L cl-r y fftt- ft.
Factltty/Owner Name 2 Facility 1D#(if applicable) ft. ft.
M e
5s Cety,aadzrp
ft.
�� PaxcelIdentificatonNo.(PIN) lr:•
5b.Latitude and longitude in
degrees/tninuteslseconds or decimal degrees:
(if well field,one lat/loag is sufficient)
t
35 03 j 7 N 80 c� t .// 22.Ce eatio .
3�
W I a�6.�M)the weII(s)o ermanent or pTemporary Sigaanae of.
WeII Contractor Date
7.Is this a repair to as a vsting well pXes or fl'�1`l0 �signing thufo�.I herebv certify that die xea(s)wm(were)gouts-cued is accordance with
If 61 is a repair. ISA NCr1C O2C_0100 or ISA NC6C 02C.0200!f'e11 Corasbucrion
fell out brown well Construction information and erplan the natrrre of
of this record has been provided to the well owner Standards and that a copy
rzpalr under#21 rvnarls 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 azy_NUMBER of wells ( 'See Over'.in Remarks Box).You may also attach additional pages if neaxss
drilled
9.Total well depth below land surface: j O�� - 24.SUBMITTAL INSTRUCTIONS
For rnrdrrp/e Wells last ail depths jdrfferoet(ezmnpk-3@200•and 2@1000 ( ) Submit this GW-1 within 30 days of well completion mp per the following:
10.Static water level below top of rasing:_ 24a. For All Wells: Original form to Division of Water Resources
If water level is above casing;use + ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 ��)
11.Borehole diameter:6" 24b.For Infection Wells: to D
Cm') COPY WR,Underground Injection Control
12.Well construction method.Air Drill Program,1636 MSC,Raleigh,NC 27699-1636 �C)'
anger,rotary,cable,direct push,eLc.) 24c.For Water Supply and ODen-Loop Geothermal Return Wells Copy to the
county enviro tal health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells prodUono over 100 000 GPD CO to D
a Yieid lgPm) Method of test:Air Permit Program 1611 MSC,Raleigh,NC 27699-1611 COPY 'CCPCUA
13b.Disinfection type: Sterllene n —5
Amount: of
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resoraces
Revised 6-6-2018