GW1--03622_Well Construction - GW1_20230526

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
I.Well Contractor Information:
Ricky Cordher
WellContraaarName FROM TO D p
2464-A �,10�` o?7.5 I' 3
NC Well Contractor Cer6ficarioa Number
Frank A. Cordher& Sons Well Drilling, Inc. FROM - TO DIAMSrER TMCXNM
Company Name ft. ft. is
�j
1.Well Conshoction Permit#: V H qO F FROM
ListaUapplicablemUconstructionpermits(ie.WC,County;State,Pan--,etc.) +1 ft. 2 7 ft. 6 1/8 'tr SDR-21 PVC
3.Well Use(check well use): ft ? ft. S`- ,aFf
�i Q Z/
Water Supply Well: �f
FROM TO DIAMETER sLOTSIZ6 TSICf4�Sg MATERIAL
❑ ❑v/�-_cam'al/Public fti -ft. in
❑Geothermal(xeafmg/Cooling Supply) E>residential Water supply(single) ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared)
01nigation, ❑Wells>100,000 GPD ! FROM TO MATERIAL ffi�LACBFffi7l METHOD&AMOl
Non-Water Supply well: 0 it. 22 fL Bentonite Hole Plug
❑Monitoring [jRecovery ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Rem fLediation i
❑Aquifer Storage and Recovery ❑Salinity Barrier FRoaf ;To
MATERIAL EMPLAC'EYII;N'rMETHOD
❑Aquifer Test ❑Stormwater Drainage ft It. '
❑F.2cp�meutalTechnology ❑SubsidenceCol ft. ft
❑Geothermal(Closed Loop) ❑Tracer
Qlb ❑Geothemnd a leating/Cooling Return) ❑Other(explain-under#21 Remarlcs) � � DEsc�o tO Ill
4.Data Weu(s)Completed:��Well M# ()fL ft.
5a.W Lotatio P ° ft.
C n Facility/OwnerName Facility 1P#(if applicable) ft. 4 .—
fL M20�.
Physical Address.City and Zt., ft. f
Ro k/al) 70 O,j"I'D- --
ty Parcel IdeadficationNo.(PIN) y
5b.Latitude and longitnde m'degrees/minutWseconds or decimal'degree(ifwell field, s:
35D3one hulang is
800-- j ' 22.Zd0n:
3 N ., yJ?
W r�
6.Is(are)the well(s): "ent or OTemporary Sigo Well Connector D�
Bvstgning thisform,!hereby certify that the wells)was(were)constructed in accordance with
el
7.Is this a repair to an eemfiag welt: ❑Yes or o 15A NCAC 02C.0100 or ISA NCAC 02C.0100 WeB Construction Standards and that a cop,ffd&is a repair,fill out btotwt VmU construction information and mpinin the nature ofthe ofdds record has been provided to the well owner
repair under#21 remark section or on the back ofill form.
23-Site diagram or additional well de>ails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well consoxdon info
construction,only 1 GW-1 is needed Indicate TOTAL NUMBER of wells (add'See over'.in Remarim Box).You may also attach additional pages if necessary.
�y — 24.S UBMTiTAL INSTRUCTIONS
9.Total well depth below land surface: 'O( ?f
For mulbple wells list all depths tfdifj rent(==Pk-3@20`0''and 2@100) (�) Subs thisGW-1 within 30 days of well completion per the following: .
10-Static water level below top of casing: vs (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If miter level is above cal use"+^ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6° Cm-) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC).
12.well construction method:
Air Drill Prog-33 1636 MSC,Raleigh,NC 27699-1636
(Le,auger,rotary,cable,detect ptab,etc.) 24c.For Water,!!Iiiii 1 11 11Den-LooP Geothermal Return Wells Copy to the
muntY envhunmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.FWp
or Water Wells utoducinQ over 100 000 GPD CO >b D
Permit Program,1611 MSC,Raleigh,NC 27699-1611 copy
CCPCUA
13a.Yield(ppm) '� � Method of test:AI r n
13b.Disinfection type: Sterilene Amount:3
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources!
Revised 6-6-2018
,