GW1-2022-01287_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
'-44;WATER ZONES
e We Contractor Name FROM TO DESCRIPTION
Oft. ka
7,5—)qrt. rt
NC Well Contractor Certification Number 45.'OUTER CASING for. Wti-.i9sedvVills)OR LINER(ifa0glipble-)-
Barnette Well Drilling, Inc. FROM TO DIAMETER`
THICKNESS MATERIAL
Company Name ) ft- I 6z ft. l 6 L4' in.
'16.-INNIER-CASING'ORNT NG
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. IL in.
Water Supply Well: ,X7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural DMunicipal/Public ft. ft. in.
OGeothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial DResidential Water Supply(shared) ',18.'GROUT
oh-rigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Uft- fL CemenVSand Poured
DMonitoring DRecovery ft. ft.
Injection Well: ft. ft. I
0 Aquifer Recharge D Groundwater Remediation .19;SAND/GRAVEL PACK(if'
OAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test El Stormwater Drainage ft. fL
DExperimental Technology 0 Subsidence Control ft. ft.
[]Geothermal(Closed Loop) OTracer
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)J FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
ft. Y- It. oo,e jejvuAA o uj
4.Date Well(s)Completed: /0— Z?!—V/Well ID# IL
5a.Well Location: ft. rt V-)A;> W4- r^N C SN4 e!
L
6(7,'
Facility/Owner Name Facility D>(if applicable) ft. ft.
ft. ft
Physical Address,City,and Zip ft. ft.
'21.RENI&RY8-7-,ra'
County Parcel Identification No.(PIN)
0 ....... .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification-
3 2 Cle ' N W
20
dle�_ t oi�
6.Is(are)the well(s): nftrr6manent or OTemporary Signature'ofCertifiJTWell Contractor z- Date
By signing this form,Ihereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or 19*b 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-I 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: 6 VO
For multiple wells list all depths if different(example-3@206'and 2@100� —fft.) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.)
Information Processing Unit,1617iMSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For likiection Wells:Copy to DWI�,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 departmentI of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
3J Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Oyu' Method of test:
4MIJOW
13b.Disinfection type: HTH Amount: 7 o cz—
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018