GW1-2022-01278_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: J
1.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
-� �°-� 70 ft ye ft � (
7 _
NC Well Contractor Certification Number 705-ft f/O it 5'0�tq• or C3
I5."OUTER`CASING for muld-;cased wells OR LINER if.a 7icable)
Barnette Well Drilling, Inc. FROM TO DIAMETER TtIICIGHESS MAOTERIAL
ft. .3 ft. in.
Company Name
�� 16.INNER'CASING OR TUBING eothermal closed,loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,Counro,State, Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) It Residential Water Supply(single) ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft p ft Cement/Sand Poured
❑Monitoring ❑Recovery ft ft.
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK d applicable)'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage It. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,gnin size,etc.)
tt ft 3 ft. [t 6 s
4.Date Well(s)Completed: Well ID# J Z -.? ft. Z Z ft W,-
5a.Well Location: ` 2. ft. ft
Facih /Owner Name Facility ID#(if applicable) ft. ft
/35-d Gh pd of-e ft
ft.
Physical Address,City,and Zip ft,
III / [-sc 21:REMARKS
ti County �i Parcel IIdentificationNo.(PIN) �O�'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification
-,36- 30 'U �y 7 N 7 S - Z !S"� � W
6.Is(are)the well(s): MNrmanent or ❑Temporary Signature`6flCe� d 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 gKo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ffthis is a repair,fill out known well construction information and explain the mature 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: < 7"D (ft) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q206'and 2@1001
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Zr (ft.) 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,NC27699-1636
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 producing;over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test
c!J
13b.Disinfection type: HTH Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018