GW1-2022-05787_Well Construction - GW1_20220615

'WELL CONSTRUCTION RECORD(GW-1) 7 For Internal Use Only:
I.Well Contra for Information:
/E �1, 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' tl ft. d
33 7
�— 5-Cc ft. ft. . I %, Ar t
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER. if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMMETER THICKNESS MATERIAL
ft. 7-6 ft O % in.
Company Name V 1
76.INNER,CASING.OR TUBING eothermat closedloo
2.Well Construction Permit#: ( ;� FROM TO DIAMETER TffiCIINESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft. fit. in
3.Well Use(check well use): ft. fL in.
Water Supply Well: FR SCREEN
PP Y FROM TO DL41fETER SLOT SIZE TffiCKNESS MATERIAL
❑Agricultural ❑Municipalt'Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) A8.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/GRAVEL PACK ifa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) []Tracer 20:DRILLING LOG attach.-additional sheets if necessary)
FROM To DESCRIPTION(color,hardness soillrock rain sue,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) e,
o ft. it a
4.Date Well(s)Completed: z 22—Z2_Well ID# �,f Z ft. ft t" A �B
5a.Well Location:
<r7t. rt.
Facility/Owner Name
Facility ID#(if applicable) ft. ft. [ '� qr u r-:
fit. fitnt C r 4
Physical Address,City,and Zip fit fit. 2022
1.Yh�•R�.:�3^�tr1�ii� ........
County Parcel Identification No.(PIN) !r;rU:id't�ii1rJ l!'JJt•,�'iti�S! i�I
,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) p / �J 22.Certification:
.� /Zd
3G . /?5 N 7t' •' / 7 W " c
11\ c +�LS— c 12 Z
Signaffire of Certified Well Contractor Date
6.Is(are)the well(s): lmanent or []Temporary
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 MINI* 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: (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@100)
^
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z 5 (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: �' (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Rotary 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) Z�1 Method of test: fc9_
13b.Disinfection type: H 1 TL�n Amoun'AhIfeup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018