GW1-2022-05786_Well Construction - GW1_20220615

WELT_,"ONSTRUCTION RECORD (GW-1) For Internal Use Only:
L.WCA C(,ntk-actor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name As,
ft. 4.?,b It. L-64-5
(;1y_" -A ft. ft. C_J
NC Well Contractor Certification Number 15.OUTER CASING(for znulti4aseid wells)'OR LINER(if applicable)
DIAMETER
FROM TO D THICKNESS MATERLAL
Barnette Well Drilling, Inc. ft. I _7 S_ IL n. 'Pvc
Company Name ('0114
..I&.mINNER,CASING OR TUBIN G'giother al doied-lobp)w
2.Well Construction Permit W 0 1 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO I)LAIMETER SLOT SIZE THICKNESS MATERL4J,
OAgricultural OMunicipal/Public ft. ft. in.
OGeothermal'(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
Mdustrial/Cornmercial DResidential Water Supply(shared) 18.GROUT
DIrrigation OWells>100,000 GPD FROM - TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. IL Poured
DMonitoring ORecovery 0 f`_ ?-C-)
Injection Well:
ft. ft.
0Aquifer Recharge 0 Groundwater Remediation 'SAND/GRAVEL PACK(if a 19. ppGable y:
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test 0 Stormwater Drainage ft. ft.
bExperimental Technology D Subsidence Control ft. fL
DGeothermal(Closed Loop) OTracer 20.DRILLING:LOG(attach additibnal,sheets if nec6ss4ry)
DGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks)_J FROM TO - DESCRIPTION(color,hardness,soil/rock type,g-rain size,etc.)
0 ft. 15, ft. '-,or, S, (
4.Date Well(s)Completed:. Well ID# WJ 's ft. Zo ft. f_ cj[Cw
5a.Well Location: C90 ft.
(or ft. r�)--oLor) - k d- 'Shne-
4 e ;K-� ft. Cq f*c 4 r
LLC [,7
Facility/Owner Name Facility ID#,(if applicable) ft. q q
CL nr �s4bq)-, OD 5
F_ ft. ft. JUN I M?
IC9"'N _
Physical Address,City,and Zip ft. ft.
LOA,- 21.RENLARKS
�J-e_ C7Q'-'z is U N
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cerh lion
0 N '7. -W
n atureof Certified Well Contractor Date
6.Is(are)the well(s): [nPermanent or OTemporary Sig X`
By signing this form,Ihereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: DYes or [INo 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 WeRg 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: I A 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: q-tv -(ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100D
10.Static water level below top of casing: c 24a. For All Wells: Original form to.Division of Water Resources (DWR),
InformationProcessing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" .
11.Borehole diameter: (a (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 Wells:Copy to the
(Le.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)_ 3 Method of test: ko'ow
13b.Disinfection type: HTH Permit Program, 1611 MSC,Raleigh,NC 27699-1611
Amount: 'E
/ff.(0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018