GW1-2022-01288_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: i
M
K:WATFR ZONES
�K FROM TO DESCRIPTION
Well Contractor Name ". J 96 ft.
3 ,726 z. � 1/►
�l4- 2 �(
3 �"- 2 loft
NC Well Contractor Certification Number
-_15.UUTERC?SING(for- ultitased 7w:llsUN "Sf liMb
Barnette Well Drilling, Inc. FROM TO DIAMETER
RIAL
Company Name V tt• / z c z
iL G r in.
16.1NNERCASING,0R.TUBING '6othermal'closed-loo ".
2.Well Construction Permit#: ,Hf FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft. fL in.
17..SCREEN_`:`.` %k ,
Water Supply Well: FROM TO DJAMETER� SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT'
❑Iai ation ❑Wells>100,000 GPD KFROMTO MATERL L EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. Cement/Sand Poured
❑Monitoring ❑Recovery ftInjection Well:❑Aquifer Recharge ❑Groundwater RemediationRAVELPACK:d,a 'tic""able
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage IL ft.
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer :'20.DRILLING'-LOG:attach:additioiiabsbeeis it decessii,.
FROM TO DESCRIPTION(color,hardness,soil/rock type, ram size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q fL ft
4.Date Well(s)Completed: ©"Z-S Zl Well ID# S3-
116 ft. ft S
5a.Well Location: C AA `t• 5-`L 49 R-O U-.0 > " S6(.
�fl R C O X Lk.-),e g ve 2-v C o RA e CL51E a `t- f va t
Facility/Owner Name ® Facility lD#(if ap icable) ft ft.
Xle-
Physical
�Adddress,City,and Zip
Cog,-6<
V
ie ® 21'..REIVIARKS` CIW —
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) —7 22.Certification: +riCt�'"' r rNi! �`"I
t'P N CV ( -7f/2— b/ W
- A�� � � ��L / 6-Z-�Z
" j
6.Is(are)the well(s): �erm anent or ❑Temporary Signature of Certified 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 welt: ❑Yes or 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: D (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@1001
10.Static water level below top of casing: 2- 24a. For All Wells: Original form to.Division of Water Resources (DWR),
(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 Ito DWR,Underground Injection Control(IUC)
n Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: „i r 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 uroducink over 100,000 GPD: Copy to DWR,CCPCUA
tL5 13a.Yield(gpm) Method of test: ,J pl-0al� Permit Program,1611 MSC,Raleigh,NC 27699-1611
T'
t� l� f
13b.Disinfection type: HTu Amount: /jo
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018