GW1-2022-01290_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
I.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
.5 3 7 6 /05- ft. �. ft S 1 t<3 an zop1
NC Well Contractor Certification Number
15.,OUTER CASING for mulltti--cased wells LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ". 5 It f in.
2 t ru C-
�l 16.INNER CASING OR TUBING mthermal closed-loon)
2.Well Construction Permit#: V FROM To I DLIMETER 1 THrCKNEss 1 MATE -
List all applicable well construction permits fl.e.UIC,County,State,Yariance,etc.) ft ft. in.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating(Cooling Supply) nRessidential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft Z ,rt. Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier 19.SAND/GRAVEL PACKifalikableFROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft fL
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sbeets-if necessa
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type.grain size,etc.)
D ft �` ft
4.Date Well(s)Completed: /6--27-Zi Well ID# �_�_ tt• f D tt• e
5a.Well Location: l o It. Y..D fe. «A l n c
It. 75 It.
-gqiIA-00L
Facility/Owner Name �Facility ID#((if applicable) 7S ft 166
ft. � `/q
ft Q ��
�Y ft J�
Physical Address,City,and Zip ft ft
21.RENfARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ;
(ifwell field,one]at/long is sufficient)
22.Certification:
N � � , � � �� � W
�r C .P,iwe
6.Is(are)the well(s): Mhle-rmanent or ❑Temporary Signature of Certified Well Contractor ! Date
_� By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or &<O 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction:Standards and that a copy
Ifthis 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 Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled:
��O 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ({t)
For multiple wells list all depths ifd perent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: Z (ft.) 24a. For All Wells: Original fokrm to.Division of Water Resources (DWR),
If water level is above casing,use'+ / Information Processing Unit,1617 IMSC,Raleigh,NC 27699-1617
11.Borehole diameter: t7 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
(L.Well construction method:Air Rota'7ry
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
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
13a.Yield(gpm) Z-6 Method of test: f1 f?� Permit Program' 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: hip -7d 1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018