GW1--07760_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ricky Corriher :14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2464-A j?pft. lid it. Lis of
ft. ft.
NC Well Contractor Certification Number ;:OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Frank A. Corriher & Sons Well Drilling, Inc. FROM 10 MAME,IER THICKNESS MATERIAL
ft. ft. in.
Company Name ge-
�/ - INNER CASING OR TUB[.NG(geothermal closed-loop),
/
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.ULC,County,State, Variance,etc.) +1 ft. 2.3 ft. 6 1/8
in- SDR-211 PVC
3.Well Use(check well use): 2-3 n' r.7_Sr---ft' L •S/Y . 1 iC Q T I C/
Water Supply Well: 17.~GREEN
FROM TO DIAMEI ER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ cipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) -
18.GROUT- iiiii?+;':iiii :
❑irrigation ❑Wells>100,000 GPD FROM TO SLAT FILIAL EMPLACEMY.N I Nit[HMI ti.A)IOC NT
Non-Water Supply Well: U ft' 22 ft. Bentonite Hole Plug
❑Monitoring ❑Recovery ft. ft.
Injection Well:
-
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Bather Fio Oi 'IF) MALE RIAL EMPLA(ENI EN I MEI HOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
V DExperimental Technology ❑Subsidence Control It. ft.
OGeothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 'I(1 DESC ill'nos I color.hardness,sod.'rock hpe,grain siic.etc.)
C ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed:/I:3T-0 Well ID# (J ft' <2Cft• ,/� f��� (� /f ��
n / ,
5a.Well Location: (J�i1/Z Q�1 2_, "t. 3 ft. IS AV,e ,,,,7,__F_4.,Grp/✓G r'h
ReS.-NCR /a�r ./U.0 ft, ft.ft. ft. •
(� Facility/Owner N Facility ID#(if applicable)
\ '' ft. ft. �' t; ' '�23
�� I A e Coat./- c1, (
Phys' I Address,City,and Zip ft, ft. nr
tv4,4 a3Sa9. 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ce catio
350331 5,1 N $� - fig; 9' W > //.-1 -�
are the well(s): Permanent or ❑Tern orary Signature of Certified\ ell Contractor Date
6.is )( ) P
By signing this form,t hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or o UA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stumlarde and:hut 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 hack of this firm.
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.
drilled: /; 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 V J (tt.)
For naltiple wells list all dcpts ifdii different(example-3G200'find 2(a1100�
(ft Submit this CW-1 within 30 days of well completion per the following:
5 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
If water level is above casing use"+"
11.Borehole diameter: 6" (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
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
(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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Li Method of test:Air Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterilene Amount: 3 la Coe
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20111