GW1-2022-05790_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GWA) For Internal Use Only:
1.Tontractor Informatio &4
! q 14:WATER ZONES -
FROM TO DESCRIPTION
Well 6ontractorName
l V _L 3o ft. +Z 7
3 t^ft. 10 P
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft r� in. 10 U
Company Name -G- _
D�A� :__16..INNERCASIN.G,OR.TUBING:, 'eothermal,closed-loop)
_
2.Well Construction Permit#: d` (J FROM To DL METER THICKNESS MATERIAL
List all applicable well construction pe fits ri.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERL>,L '
[]Agricultural ❑Municipal/Pablic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.:GROUT: .
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. Zfl ft ^� P.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
-19..SAND/GRFvEL PACK d.a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20::DRILLING LOG attach additional sheets if neces'sa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft. it ( l/C!T w r r
4.Date Well(s)Completed: � Well ID# W T 1 'C1 ft. ft PYID--J n /✓._
5a.Well Location- ft. 2 ft. QAA
5 ii
gk- ft. to ft
acility/Owner Nam'/e� P�/� Facility ID#(if applicable) ft. ft.t��f ft .. ft
ft ft.
Physical Address,City,and Zip �i �./
U // �� �� <� 2I.REMARKS
County Parcel Identification No.(PIN) lyyr< sew�" ;fy
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) p p 22.Certification:
2 W &em�152
6.IS(are)the well(s): rJPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo 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 weld 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
(add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: fY 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 0 (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@100)
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" !
/' G{ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
f
11.Borehole diameter: (J (in.) 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
(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
C� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
-13a.Yield(gpm) 2u� Method of test:
13b.Disinfection type: u I-1-u n Amount: 1/2 C u p
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018