GW1-2022-01294_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name /boft. 2-.Di>IL
-35 7-9 6- x
NC Well Contractor Certification Number nm oL, It.
J5.OUTER CASING(foe multi-casediWelh)0 LINER
Barnette Well Drilling, Inc. FROM I TO I DIAMETER T%__ MQATERIAL
Company Name ft- I 'Sy fL 6 1��in. I S
ii
A&INNER CASING ORX ING,(Redthernil Ulbsid-lbolij-,
FROM TO DIAMETER TMCIMSS MATE
2.Well Construction Permit#: 7 : in.
RIAL
List all applicable well construction permits(i.e.UIC,County,State. Variance,etc.) ft ft.
3.Well Use(check well use): ft. ft. in.
717.SCREEN,
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS I MATERIAL
OAgricultural OM[unicipal/Public in.'
OGeothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. It. in.
0 Industrial/Commercial El Residential Water Supply(shared)
-6M
CIrrigation OWells>100,000 GPD FROM
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ftGemvm4-QeRd Poured
OMonitoring ORecovery ft 13 ft.
Injection Well-. ft.
0 Aquifer Recharge OGroundwater Remediation
19'ISANEilGRAVEL!PAC-K.(tfalspliiibley.
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test El Stormwater Drainage ft. ft.
OExperimental Technology OSubsidence Control ft. ft
OGeothermal(Closed Loop) OTracer 20.4RIL,LANG,LOG'(atta -�WUH64slketsif iiefeskiry)
OGeothermal(Heating/Cooling Return) 00tber(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rack type,grain size,etc.)
0 ft- 51 It. 0 0 &
4.Date Well(s)Completed: &-q-24 well ID# 01-z,1bBz 7 3
Sa.Well Location: k-ft. 3S fL 1':5-AAhe gyc&
CA AJ'516VA J-0 56--Z 34—ft. #_3 fL se>1f4 9 4py 9L6c:1e,
Facility/Owner Name Facility ID#(if applicable) Y-S ft- 6 ft-&- 6XJ,+!1 COL
rVlfgg�oe.L� L�ltl /q, fL ft. I
Physical Address,City,and Zip ft.
Llfilve-e
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat'long is sufficient) 22.Certification:
N 7 W
0:22t
crWT
6.IS(are)the well ZPE'Irlmanent or []Temporary Signature of Certifie e l Contractor
Date
By signing this form,Iherekv certify that the well(s)was(Were)constructed in accordance with
7.Is this a repair to an existing well: OYes or *<01 15A 1VCAC 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-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: (ft.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@1001
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+-
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy4o,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,directpush,etc.)
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells produchi:a over 100,000 GPD: Copy to DWR CCPCUA
/ /V�- Permit Program,1611 MSC,Raldigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount:'"Maw -Z-9 D
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018