GW1-2022-01256_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Nell Contractor Information:
d v .14.,WATER:ZONES'
;Il Contractor Name —EROM TO DESCRIPTION
-it
NC Well Contractor Certification Number . f t S!d f t l �5
AS.DUTER CASING for multi-ca2i8a wells OR LINER if a 'livable) - -
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MAT RIAL
Company Name � � SO.
q :16:3NNER:CASIN0.OR TUBING 'eothebmal closed-loo '
2.Well Construction Permit#: S✓ Zs 'T FROM TO DIAMETER TffiCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): tt ft in.
Water Supply Well: .17.'SCREEN';
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) -
18.GROUT
❑hri anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a Z,c. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
❑A uifer Recharge ft. it.
4 rg ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19.;SAND/GRAYEVPACK rf abbblicable .
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer k20'DRILL•ING LOG'attach additional sheets-if neces ii . '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock e, in size,etc.)
6 ft- �r-
4.Date Well(s)Completed: /0 7 Well ID#35 /3 C� 7 ft IL S©
5a.Well Location: AC ft, 34�S ft
/�f;�PuX—s- ft (© ft / -;a6 P—A U e—
Facility/Owner Name Facility ID#(if applicable) & 5-Lb
,4 793 d1,©dz j a�, 20,44 ft ,3
Physical Address,City,and Zip ft ft.
�21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: AN I
(if well field,one lat/long is sufficient) 22.Cerd on:
24- f ��� N 7 S - 9-bz sf�l3w s.
`Qr:7- z
6.IS(are)the well(s): 0'ermanent or ❑Temporary ignature 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 5??T- 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 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 (ft.)
For multiple wells list all depths if different(example-3Q200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: z (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+/ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (3 (in,) 24b.For Injection Wells:Copy;to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constriction method:Air Rotary
ry
(i a inner,rotary,cable direct p
, , 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells Producinls over 100.000 GPD:Copy to DWR,CCPCUA
/ Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) < Method of test: Awe
13b.Disinfection type: HTH Amount: Z Z a
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-201 R