GW1-2022-01277_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14L WATER ZONE&,.,
Lo.4/'t" FROM TO DESCRIPTION
Well Contractor Name ft. Z-4-1 i I
4 5,0 a�
/* ft- -76�p-,-I / �L ?0 ZJ�
NC Well Contractor Certification Number 16.OTJTEWCASJNG,Ooijhitlti� ei v0ellg! 'R LINER`(if ap- liv�I
Barnette Well Drilling, Inc. FROM DIAMETER in. THICKNESS q
ft. ft .5A(?_2_,I (J Lr
Company Name NL
I&INNE R-CA S I NG OR-TUBING'(&dtherm2l clbsed-1660)
2.Well Construction Permit#: A -71 FROM I TO f DIAMETER THICKNESS MATERIAL
permits(i.e.UIC,County,State, Variance,etc.) f, f, in.
List all applicable well construction pe i
44WATE"
FROM
10 .
ft ft.5 TER
..M
"A
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ~
oAgricultural C]Municipal/Public ft ft. in.
oGeothermal(Heating/Cooling Supply) In Residential Water Supply(single) -f t. ft.
DIndustrial/Commercial CResidential Water Supply(shared) 18.GROUT
01trigation OWells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- GewmaU,%wd Poured
DMonitoring EIRecovery 0 ft. ft.
Injection Well: ft ft.
0 Aquifer Recharge DGroundwater Remediation
1 W.SAN ACK 01tchbli)---br/GRAV-E0-P cif-iiio
CAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test OStormwater Drainage ft. ft
0 Experimental Technology 0 Subsidence Control ft ft.
DGeothermal(Closed Loop) CTracer 20;-,DRILL-ING.,LOG,(afthch id4ti6biI sbee&ff iie_idssa
OGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM ft. TO- fL DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
-:5 6a e,
4.Date Well(s)Completed:Z2Lt&-,2 I Well ID# R 71 -5- ft. 12- ft g ecN_
5a.Well Location: 12-ft. ft. rq
If--5-` 1 6, y e6a, 4-.5 4
Facility/Ownef Name Facility M#(if applicable) K5t- -5-F"Oft. 6; KIZ) v R_ncz<
ft. ft.
.&0 Y
Physical Address,City,and Zip 4 ft. ft.
7 T 77 77 7
-Z, .7 Of 21,RE74ARJKS..,_-
JOE
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: S!NG V.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): &K-rmanent or OTemporary
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 0yes or 9940 15A NCAC 02C.01�Oo,15A JVCAC 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
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells i
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2-o 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@1 00�
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (in.) 24b.For Injection Wells: Copyl to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
1
12.Well construction method:Air Rotary 24c.For Water Supply and Open-Loop 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 producinIg over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: MP-QW ?_512z�
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018