GW1-2022-01253_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J4.,WATERZONES
Well Contractor Name FROM TO DESCRIPTION
t10 ". a6;- ' le,'614�
NC Well Contractor Certification Number IS:OUTER CASING for cased wells'' livable
Barnette Well Drilling, Inc. FROM To multi
FOUMM MATERIAL
Company Name o ft. l IL ��c in. )?U
6
16.YNNER.CASI NG'OR.T ING(&othermaVclosed_1o60)�;
Z.Well Construction Permit#; -7 6 t FROM TO DIAMETER TBICKNESS MATERIAL
ft. in.
List all applicable well construction permits(i.e.UIC,County,State, Variance,et.) ft.
3.Well Use(check well use): ft. ft. in.
—77-
Water Supply Well: 17.:SCREEN'FROM TO DIAMETER SLOT SIZE CKNESS MATERIAL
OAgriculturul 01VIunicipal/Public frt ft in.
C]Geothermal(Heating/Cooling Supply) 2ITesidential Water Supply(single) ft. ft. in
01ndustrial/Commercial DResidential Water Supply(shared)
I&GROUT
DIrrigation DWells> 100,000 GPD FROM — TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1,r ft- Cement/Sand Poured
DNIonitoring DRecovery 15- 't- A 0 ft.
Injection Well: ft. ft.
DAquifer Recharge DGroundwater Remediation 77
.I9;.SANVGRAVEVPA0K(if
•Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test DStormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft.
DGeothermal(Closed Loop) DTracer
0 Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks), FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft- �5- ft. 4 1. /,, 6 A A
4.Date Well(s)Completed: Well ID# I 76 ft. IL
5a.Well Location: 7 6f
'L)'dota 5 :7 s-ft. q_5- ,t- I
Facility/Owner Name Facility ID#(if applicable) ft- )66 ft- I-r,: cc<
39 40!!1AS- PM1
Physical Address,City,and Zip ft ft
21'
W eeltl "2_Pri-2)'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
N 7 q , 2-2 0 7a W
6.Is(are)the well(s): til-e-rutiment or oTemporary 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: Dyes or 9"4 15A 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 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 I GW-I 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.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
(ft.) 24a. For AD 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 Rotary
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.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
6/0 U-X--k Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018