GW1-2022-05791_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We ontractor Informatio :
.�
I ZONESFROM TO DESCRIPTION
Well Contractor Name
3 ft. ft
ft. �96 ft- � �r 1
NC Well Contractor Certification Number 15.OUTER,CASING for multi-cased wells OR LINER(if aP livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
ft. fL W in. I S(D 1a (1e
Company Name
1 cJ INNER.CASING.OR TUBI(G: eothermal closed-loop),
2.Well Construction Permit#: s� l` �� FROM TO DIAMETER THICI4�1Ess MATERIAL
List all applicable well construction permits C.e.UIC,County,State, Variance,etc.) ft1; ft.
in. �� I p416
��
3.Well Use(check well use): ft. ft' in.
i
Water Supply Well: 17.FRO SCREEN TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Ieating/Cooling Supply) [']Residential Water Supply(single) fL 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: 42
ft Z ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediafion
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.-DRILLING:LO,G. attach,additional:sheets,if:necessa ' wL
❑Geothermal(Heating(Cooling Return)
TO DESCRIPTION(color,hardness,soilfrock e, Z size,eta)) ❑Other(explain under#21 Remarks) ft.l ft.
_
4.Date Well(s)Completed: 'l Z-z� Well lD# {- U p S Z ft. ft. J�
5a Well Location: ft. ft
f^i(_0(1 f h_(- 1/��5 1'J✓( /^ ft. F1 ft
J t
11 c�
Facility/Owner/N'ame f / n 1 j !Facility ID#(if applicable) ft. ft.
3y� (3-rA°1�1 a''/im1� Y/f, ` IJI"�S�DfJ�cG� L-72� ft. ft. `
Physical Address,City,and Zip ft ft.
21.REbIARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification l+``•'^'{t'.y ..,{')';
9' N 2 a d 6 6_' W
Signature of Certified Well
6.Is(are)the well(s): Permanent or ❑Temporary Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 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:6®o (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-9@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 (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)
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
�( Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: l
13b.Disinfection type: HTH Amount: 1/2 C u p
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018