GW1--07329_Well Construction - GW1_20231113

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Rick Corriher .. ,: .- . : :.:. . .:.::.:.::.:..•-..:::.. ::...::..•..::-:: ...::-:.:.::.:.:.-. iiiigi.:::...
;1.,.N�ATERaA.NESi:>:ii::is�iiti::: :<�::::;:i3i:<?;�:;: <:?,::.i;:o: i>=i•:i::%?i::i`:c :::i:<�:�:r:i:;::::::i:;:;::�:i::i>si::::
Well Contractor Name FROM TO - DESCRIPTION
2464-A /3 ft. ft.
Y5 ft. `'�� a
l NC Well Contractor Certification Number
.1.:WILIFf lWik.q•`.0.(for:iii iiiRii l:ii_ibi OR<TINEgii(if'ap'liailS .♦: iiii i iii
Frank A. Corriher-& Sons Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 in.
Company game
(J 6 O 9 it 16 INNER.CASING t]R:?iiBi{rIG,(geottienuahclosedlnop) ;...;. ., ♦.:..... ..... .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.ULC,County,State, Variance,etc.) +1 ft. /tY yft. 6 1/8, in. SDR-211 PVC
3.Well Use(check well'use): l a LID. /G P. /'.iyin• cr- g/f/
Water Supply Well: :17..,CR.EEN: . : . . ..-:.:....::.::......:. . . :.. .. ..,:.,.:.::, .: ,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑M cipal/Public ft. ft. in. '
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial DResidential Water Supply(shared) .:::::.;,;: . .::,,.:.: ::::.:,.::
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
;,` Non-Water Supply Well: 1 0 ft' 22 ft. Bentonite Hole,Plug
OMonitoring DRecovery ft. ft.
Injection Well:
ft It
DAquifer Recharge ❑Ground water Remediation
..19,.SA(Vb)GRA\'EL.LACKGrf.applicable) .....,..
DAquifer Storage and Recovery ID Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
01 DAquifer Test ❑Stormwater Drainage ft. ft.
Q DExperimental Technology ' ❑Subsidence Control ft. ft.
,
❑Geothermal(Closed Loop) ❑Tracer 20:iPRTLLING:hOU.(attach:arldittorialsheetirFnecessa[j) , ....: Mi
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rack hpe,grain size,etc.)
U ft. O ft.
4.Date Well(s)Completed:/ .25 3 Well fl ft. /Q�ft. St D Ao--(C
e 5a.Well Location: tj'^) /6‘ft. /L, ft. p ,1 /�� j •
.., y , it (/elr�• �'C 'l�7e t%� /'�li�/1aS ft. ft. '� ,
-, Facili y/Owner Name L t Facility ID#(if applicable) e-I(�G,�s ft. ft. 1 -
a a ke• sP 1 fot/M / \G/1 41`//Ot.a2,i' j(/1e ft. ft. 1 t . o
Physic Address,City,and Zip fit, ft. NOV V ,`,-20 2�
KO i4,4, S. „,„„ .`a „..,? ' ' z ..... .. ..„ •`i? .; '=isi: E:i::<'s isi i i: i# % . :s . % s
County Parcel Identification No.(PIN) r+t • !'`-%G
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, e lat/long
t —J /sufficient) 22.Cert' cation
-350 N 80� � r l� 1 _ 0 — r22
. 6.Is(are)the well(s): l�Permaneitt I or OTemporary Signature of Ccrkficd\ ell Contractor Date
�t� By signing this form,!hereby certify that the well(s)was(were)constru cted in accordance with
7.Is this a repair Ail an existing well: DYes or i I o 15A NCAC 02C.0100 or 154 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 hqs been provided to the ueli owner.
repair under#21 remarks section nr on the hack of this form.
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'See Over'in Remarks Box).You may also attach additional pages if necessary.
chilled: �j 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: [/‘J (ft') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all•dept/rs ifdii ferent(example-3E1.2.00'and 2611001
�`J 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: v (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
(Twofer level is above casing,use"+" 1 •
6" 24b.For Injection Wells: Copy to!DWR, Underground Injection Control (IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Ai r D ri
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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 dyer 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
Sterilene a`' D
13b.Disinfection type: Amount: °2f S
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018