GW1-2022-05784_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
i !f 0 ft. /5-.0 it.
—3 3 7/ V X ft. F/ 3 ff ft ! C�
NC Well Contractor Certification Number 15:,OUTEWC-ASING for multi cased�w`ells)OR LINER(if a Gcable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
It. S J ft. G in. (Z "1 1 c
Company Name
16.INNER CASING OR TUBING. eotliermal closed-loop)
2.Well Construction Permit#: Z '�� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR M REE TO DIAMETER SLOT SIZE 1. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
-❑Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) et. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METROD&AMOUNT'
Non-Water Supply Well: ft. Z Oft emroYdtand Poured
❑Monitoring ❑Recovery ft. ft. 'e
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation
19::SANIDIGRAVEL PACK(if a licable),
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. -
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG, attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,ssoillrock type,grain slze,eta)
ft. S ft. 10
tt`` Z dSd-�
4.Date Well(s)Completed: T'�-��2� Well � ft. IS
ft. (e
Sa.Well
Location: rr ` .0 ft. Z ft. . 7
It-
Facility/Owner Named Facility ID#A(if applicable) ft. ft.
l l r3 dt A+A/��b iy ey �1L� f ���i j f ft' ft.
Physical Address,City,and Zip R FF
tt. ft.
ly,q S�e— y ZI:REMARKS y -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong1is sufficient) (,1 22.Certification:
6.Is(are)the well(s)• CIP.ermanent or ❑Temporary Signature f 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: ❑Yes or ANT_ 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: C7 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(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- 5 (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 to DWR,Underground Injection Control(IUC)
12.Well construction method:A Ai r Rotary y Program,1636 MSC,Raleigh,NC 27699-1636
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 producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) ! L— Method of test: p ,r-
13b.Disinfection type: HTH Amount: ?
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018