GW1--03624_Well Construction - GW1_20230526

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1.Well Contractor Information:
Ricky Corriher --Well Contractor Name FROM TO DESCMTION
2464-A ft ��ft
NC Well Contactor Ceitification Number �
Frank A. Cornher.& Sons Well Drilling, Inc. FROM TO DIAMETER THTCKN_S3 MpTEurer.
R in
Company Name - ft ,
2.Well Construction Permit#: _ U ' FROM TO - DIAME1EFt THICIINESS MATERIAL
List all applicable well construction permits i e.UIC,Countv,State,Variance,etc.) +1 & (l ft 6 �8 in SDR-21 PVC
3.Well Use(check well use): ft
Water Supply Well:
FROM TO DL111fETER SLOT SIZE THICKNESS MATERIAL
❑ ❑ cipal/Public ft it in
❑Geothermal(Heating/Cooling Supply) � esidential Water Supply(single) ft —it in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑hri anon ❑Wells>100,000GPD FROM TO MATERIAL I O;iFl CEMENTMFMODBcAMOUNT
No Supply Well: 0 ft 22 ft Bentonite Hole Plug
,,;-Water
❑Recovery ft. it.
Injection Well:
It. ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑$alinity Barber FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. rt
❑Geothermal(Closed Loop) ❑Tracer -
C CRIPTION❑Geothermal FROM TO DES color,hardness,soiyrock(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft z ft. � sire,etc)
4.Date Well(s)Completed:�J~�—M—/ Well EN .70 ft. ft
Sa.Well Location: It.
G/ f)t,S1to.- '( ft ft.
(\ 1 Facility(Owner Name F ility ID#(if applicable) M ft. 4 '� �� y -y y
I�YJ G �� / ., ft. M 1
/ fL
Physical Address,City,an Zip v ft. ft
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Mong is sufficient) L2.:Cecati
35o,t3� ��,� N 800 a-7C7 o -6-9 " W
3--7
6.Is(are)the well(s): bf ermanent or ❑Temporary „ Signature of Mrtified Well Contractor Date
By 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 pfVo. ' 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known 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 of this form.
23.Site diagram or additional well details:
8.For GeoprobelDPT 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: (ft)
For mu1iiPL-wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following: ;
10.Static water level below top of casing: O ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) 24b.For Injection Wells: Copy,to DWR,Underground Injection Control(IUC)
12.Well construction method:
Air Drill Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells Copy to the .
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:t 24d.For Water Well producing over 100 000 GPD•Co to D
' s
13a.Yield(gpm) _ J -O Method of test:Air Permit Program,1611 MSC,Raleigh;NC 27699-1611 p� ,CCPCUA
�
13b.Disinfection type: Sterilene Amount: S
r
Form GW-I North Carolina Department of Environmental Quality-Division of water Resources
Revised 65-6-2018 .