GW1-2022-01289_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-,1) For Internal Use Only:
I.Well Contractor Information:
-�- IA/�(-J'� 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
NC Well Contractor Certification Number f V-'s ft. t3 ft G t fR 2--5d = ,Z�Ja p t
15.OUTER CASING for multi-cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIM ER THICKNESS MA�TTE`R'IAL
Company Name
P Y O ft. ft. in. �c92 1 V V L
16.INNER CASING OR TUBING10liatherm2l closed-loo
2.Well Construction Permit#: 16 FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) l�idential Water Supply(single) ft. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18..GROUT
❑Tmgation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt ZG ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
DAquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19:'SAND/GRAVEL PACK ita licable
h' FROM TO MATERIAL EMPLACLMI NT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. 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,grain size,etc.)
6 ft tt leu12"Ab 1✓to
4.Date Well(s)Completed: U v-2 Well ID# f�l� cf., ft. G� ft
AP
5a.Well Location: A�t�A
ut f r'/i R m -4-K bey ll �r6oft. 6:K&
Facility/Owner Name Facility ID#(if applicable) ft. ft.
fnt4V.Q 'C6 21mv i t;e t--5 �_ ft. ft
i
Physical Address,City,and Zip ft. fG
11.REMARKS IAN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I� y
(if well field,one[at/long is sufficient) 22.Certification' li tt
36' �Fy277 N _ -Z 4 w /D—Z,fa"'2.i
6.Is(are)the well(s): L&ermanent 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
�F
7.Is this a repair to an existing well: ❑Yes or W 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 I 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: 2-6 (ft.)
For multiple wells list all depths ifdierent(example-3@206'and 2@100D Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 2,j (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy I;to DWR,Underground Injection Control(TUC)
Air Rota 1�� Program,1636 MSC,Raleigh,NC 27699-1636
.Well construction method: '1 24c.For Water Supply and OneA-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable direct push etc.) county environmental health depar`tment of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
�C} !� Pert Program, 1611 MSC,Raleigh',NC 27699-1611
/ (A) tm
13b.Disinfection type: HTH Amount: 6 Ze
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8