GW1-2022-01251_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
( /1�(�1f1�. l� LL 1 14:'WATERZONES
FROM TO DESCRIPTION J
Well Contractor Name ?eft. / 0 ft 3 to-�
3-7 7o )I5:iO0
TERC NG for_miilh cas 15 t 7`' JPa `
ft. ft
NC Well Contractor Certification Number ��Yelis'?OR.'LINER:ifa '7icable
Barnette Well Drilling, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
ft. d ft. in" 1 VG
Company Name - !se
/ /�� 16.7NNER CASING OR TUBING"eot6ermal closed-loo
2.Well Construction Permit#: b FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): it. ft.
Water Supply Well: i.17.SCREEN
FROM TO DIAMETER; SLOT SIZE >THICKNESS` MATERIAL ^
❑Agricultural ❑Municipal/Public ft. ft in
❑Geothermal(Heating/Cooling Supply) 17Residential Water Supply(single) ft. ft. in•',.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑hri ation ❑Welis>100,000 GPD EFROMITO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . � Poured
❑Monitoring ❑Recovery ft.Injection Well:❑Aquifer Recharge ❑Groundwater Remediation
RAVEL'PACK if a lica6le ,'�s,'• � r.'M%
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer °20:'DRILLING;LOG. attach,addiiio6il sfieets:if nec6ga 3- i
FROM TO DESCRIPTION(color,hardness,soil/rock e, in size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
l/ rt. ft 6 �72 Eck- c�
4.Date Well(s)Completed: 1 Z �— "Z 1well ID# G© Y ft. ft e q-s& T
5a.Well Location: L (x ft. D ft to S 61),
T G�� fl e u 5 T 6 it. q 0 It AU Z) r
Facility/Owner NV6e Facility ID#(if applicable) 90
it. Z 06ft"
33_1 d e k -/ex ��5 ��- ft ft.
Physical Address,City,and Zip (� ft ft. r a r n^•!-4
'0LIL6 ,.21.REMARKS;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/Iong is sufficient) 22.Certification:
36 - ZG 9SJN 79— z_` & U W
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified 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 1 SA NCAC 02C.0100 or 1 SA 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 oJ'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 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: Z Q (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z-5' (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" I
11.Borehole diameter: 6 (in.)
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,N027699-1636
12.Well construction method:Ai r Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) county environmental health department ynent of the count where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
D-�u
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: H I n Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019