GW1-2022-04106_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well C tractor Information:
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Well Contractor Name /I& ". /---p-OIL
33 7'� - 2 5
NC Well Contractor Certification Number
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Barnette Well Drilling, Inc. FROM I To__L____[-DIAMETER AMCKMSS MATERIAL
Company Name I&JNNERft. ft I '<P' I-.�- 1-5h-R 211 rvc
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2.Well Construction Permit#: L 3 FROM- ITo DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural OMunicipal/Public ft. ft. in.
DGeothermal(Heating/Cooling Supply) XRicrsidential Water Supply(single) ft. ft.
01ndustrial/Commercial EIResidential Water Supply(shared) 18
..,'GROU4T
,
DIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft- Zed ft- Cement/Sand Poured
E]Monitoring DRecovery ft. fL
Injection Well: ft. ft.
•Aquifer Recharge OGroundwater Remediation
19;;SANtl/GRAVEL
•Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETH D
DAquifer Test OStormwater Drainage ft. ft.
DExperimental Technology OSubsidence Control ft. ft.
OGeothermal(Closed Loop) OTracer 20.-DR]ILL71N G'10r"(a
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM ft. I TO 1� ft. DESCRIPTION(color,hardness,soil/rock type�grain size,etc.
J1
4.Date Well(s)Completed-2-/, a2- well ID# Z 3 ft. Z ft. C/A
5a.Well Location:
on "L IL
Facility/Owner Name Facility ID4(if applicable) P.T-ft. yac�- L r'&3i�n�vfG
ft. ft.
Physical Address,City,and Zip ft. It.
Ae S y e165
11-.zREMAPUK&- %
v
2
County Parcel Identification No.(PIN)
APR 18 2077
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
,P 6-I-Pb X,4 N W WU
'4 r
6.Is(are)the well(s): 94're'rmanent or OTemporary 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 well: OYes or NN15" 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:twell owner.
repair under#21 remarks section or on the bock 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: 2-0 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@100�
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: 2 J (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: g (in.) 24b.For Injection Wells:Copy,to 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 Welts:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health dep"ent of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
Permit Program, 1611 MSC,Raleigh,
NC 27699-1611
13a.Yield(gpm) Method of test: d�lcy olle_�
13b.Disinfection type: HTH Amount: 2
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018