GW1-2022-01286_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
y� G L LIA
3 l U A2 1�L� �Z 44,WATER ZONES._
Well Contractor Name FROM TO DESCRIPTION
C36ft. /C&It. Z 10,
�.� �mb I ze. l o ft X ? a}l &�•J i cue irys
NC Well Contractor Certification Number 15:OUTER:CASING f6i'multi case well's'OR I}INER,if a licable
Barnette Well Drilling, Inc. FROM TO DI4METER THICIGYESS MATERIAL
ft. C� ft in. S�
Company Name 1 R
R � � 16.1NNER GASING OR TUBhYG'`eotbermaFcloserl-lori
2.Well Construction Permit#: FROM I TO I DIAMETER L THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. it in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: :17.SCREEN.
FROM TO DL4METER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT.. v
❑frri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f. ft Poured
❑Monitoring ❑Recovery ft Z ft
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
14:;SAND/GRAVELPACK if:,a 'livable "
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage fr. IL
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20i'MRIf.LING:LOG(attach,idditioniPsheetsifnecessa.` ?.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
�p f' 3 U e uO�
4.Date Well(s)Completed: O— f' Well ID# /7 7 ft. ft r '*-,
5a.Well�Loc/aattionQ / ( ft. Z�- ft
,Pae
Facility/Owner Name Facility M#(if applicable) ft*
PeS rt& �r]r C�.f2/!� e14� /v ft ft
Physical Address,City,
`and
-�Zip i
E its e>0t 21,"REMARKS
�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
6.ls(are)the well(s): �manent or ❑Temporary Signature of Certified Well Contractor! Dace
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LAN 15A NCAC 02C.0100 or 15A NCAC 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
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: �. © � (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q206'and 2Q100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: g (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: Copy!to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
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 producini 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: HTu Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018