GW1-2022-01274_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
l(�/1 ►' ��Cam/ U.-WATER ZONES p
Well Contractor Name r FROM TO DESCWMON
3_—/�� o o ft fti f
NC Well Contractor Certification Number f 710 ft• r bJp ft 2 l Z {�2TQ fReq
15.-::OUTER'CASING'(for multi-cased wells)OR LINER:ifa livable :.'
Barnette Well Drilling, Inc. FROM To I DIAMETER THICKNESS MATERIAL
Company Name d ft So ft (/
16.•INNER:CASING OR TUBING` "e`othe maliclosed4bo t
2.Well Construction Permit#: 7/S FROM I TO I DIAMETER I THICKNESS I MATERMI,
List all applicable well construction permtts(i.e.UIC,County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): % ft in.
Water Supply Well: `17..SCREEN.
OA Cultural FROM TO DIAMETER SLOT SIZE THICKNESS' MATERIAL
❑Municipal/Public ft. ft. hi.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single)
ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18JSROUT.
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&avtOUNT
Non-Water Supply Well: 8 ft. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
❑A uifer Recharge ft. ft
4 g ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19:=SAND/GRAVELPACIC tf:' livable
ty FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft R.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRiLM G LOG attach additionalsbeetv`if ne"ciW`a ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock e, rain size,eta)
ft ft. 6
4.Date Well(s)Completed: -I - L!Well ID# / ft Z ft " e i
5a.Well Location: Z ft- ft 4 9 uS i
S 3 p ft ft 7; ,V o C ie
Facility//, /O $Name Facility ID#(if applicable) 7 ft 2-66 ft
I-//elk/ Y tU ft ft !L
Physical Address,City,and Zip ft ft.
S S 21:'RENIARICS:.; :'
County Parcel Identification No.(PIN) " A N d'2 ^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ea
�9 Z N 7 Q Z /577 W
7 Z 1
6.Is(are)the well(s): 113Pt=-anent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well($)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 614 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
1f 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:
Z 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple wells 11st all depths}'different(example-3@200'and 2@100� ----(ft.) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5J (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: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Supply and Open.Loop Geothermal Return Wells:Copy to the
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 m Permit Program, 1611 MSC,Raleigh,,NC 27699-1
(gP ) Method of test: 611
u u (y
13b.Disinfection type: HTH Amount: 7 d
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6.6-701 A