GW1-2022-05785_Well Construction - GW1_20220615

WELL'CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.WbIl Con
tractor I}nfformation:
U4✓f #0 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name —7 ft. C10® tt %(y
2 e/�S 70 ft. Ad ft- U
NC Well Contractor Certification Number 15.:OUTER CASING(for multi-cased wells)_OR LINER. if a licable)
Barnette Well Drilling, Inc. FROM TO D R THICKNESS MATERIAL
ft. 4 � ft. q in. 19'' U�
Company Name
i,( �) %.� /� 16:=INNER CASING OR TUBING eothermalclosed-loo
2.Well Construction Permit#: %9 t/" �/y�" FROM To DIAMETER I THICKNESSMATERLaI.
List all applicable well construction permits rt.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft in.
Water Supply 'I7.SCREEN
PP Y Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERLAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,18:•GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: () ft- ft Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVELTACK if a licable'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACFrIENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology El Subsidence Control ft ft
❑Geothermal(Closed hoop) ❑Tracer 20:DRILLING"-LOG attach'4additionaLsheets if necess `Y s
FROM TO DESCRIPTION(coloF,hardae ,soil(rock rain size etc-)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) e, '
62 ft. 2-0 It. O
4.Date Well(s)Completed:{ 2 Well ID# D Z -2,C) 60 ft �d"z-C
5a.Well Location: 6.v ft. (4 ft. 'w- OC p g
ft. ft.
SI
Facility/Owner N/ it'it G�P/1a'me y� JQ Facility IID#(if applicable) ft. ft.
z)G C 'git �P�O I! (>'i'�/'� ft. ft J ? `
Physical Address,City,and Zip �/ (� ft ft.
i'`S�j CY ? t'�/� 2I'."REI4IARKS remv°.- ..;6 /fi GEE
C-3P"nIlk\I"
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifw//�ell field,one lat(long is sufficient) 22.Certifica On:
3bfd q� 7 0 fZ N ���qt� 17�� �1' f�/ �- z zs zZ
IP
6.Is(are)the well(s): Permanent or ❑Temporary Sifnati e of Certified well Contractor Date
•\ By signing this for m,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or *0 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis is a repair,fill out known well construction information and explain the nature of the o fthis 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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@206'and 2@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: " (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"i/ °
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method: A
11.Borehole diameter: � Rotary
1636 MSC,Raleigh,NC 27699-1636
ir I�otat�/
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 Producing over 100,000 GPD: Copy to DWR CCPCUA
13a.Yield(gpm) '-t
j a Method of test: Q Permit Program,1611 MSC,Raleigh,NC 27699-1611
.y� U
13b.Disinfection type: HTH Amount: F0"
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018