GW1-2022-01254_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
RILV1211'k L, Y- 1r14 WATER_ ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft
Z_ 2-
z Z_a
NC Well Contractor Certification Number
15..OUTE,RCASI,NG.(f6r ulfi-ciised'Wtl- l�)OR LINER,,Ctfilo li6blO
To
Barnette Well Drilling, Inc. mom TmAMETER tTRICKNESS li MATERIAL
L-) in.
Company Name
_,16.JNNER;CASINC.OR ING12iothermal dosed-lbop)
2.Well Construction Permit 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) oft. ft. Lf in.
3.Well Use(check well use): ft. ft in.
:.:;
Water Supply Well: -11.SCREE?4 FROM TO DIAMETER', SLOT SIZE THICKNESS MATERIAL
OAgricultural 0Municipal/Public ft. ft. inr
OGeothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. im
01ndustrial/Commercial OResidential Water Supply(shared)
I&GROUT
0 Irrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: Oft- ft- Cement/Sand Poured
DMonitoring DRecovery ft. ft.
Injection Well: ft. %
0Aquifer Recharge CGroundwater Remediation -19.lSANDJGRAVEt PACK(ifapp livable) ......
0 Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ClAquifer Test 0 Stormwater Drainage ft. ft.
DExperimental Technology 0 Subsidence Control ft. fL
DGeothermal(Closed Loop) OTracer 20 DRILLING LOG ztadh,additiofiilAkefsjfjiecessary '
OGeothermal(Heating/Cooling Return) C30ther(explain under#21 Remarks) FROM ft TO ft. DESCRIPTION(color,hardness,soil/rock type, in size,etc.)
-o Zf,- 0 0 e.-2 b ,, fC
4.Date Well(s)Completed: Well ID# ZL ft. —ft- —
AA�l
A 1
5a.Well Location: ft-
5�4g= f,- 2S,6 fL 6,
Faciliffy/Owner Name Facility ID#(if applicable) ft. fL
ft. fL
Physical Address,City,and Zip ft. 1'7
"tom R ,21.REMARKS"', Z
12 4 r,-1 11-31176
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tatllong is sufficient) 22.Certification: 21
31K ,1 797—/ N ? L<Y W
6.Is(are)the well(s): 6Kermanent 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: OYes or Wo 15A NCAC 02C.0100 or 15A 1VCAC 02C.0200 Well Construction Standards and that a copy
lj'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: Z,!if 0 —(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@206'and 2@100)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (t) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells:CopyAo DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NU 2 7699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loopi 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 over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gp.) 12— Method of test: Permit Program,1611 Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1S�'� T' I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018