GW1-2022-05796_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
R&/V/f/I to t 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
''7 / /� 70 ft. Z ft. 6 �,
3 / b �/? ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells UR LINER if:a lieable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
QQ /t ft. /V ft. 4 in. ` Lt
t�'zt�l l v/
P � � ���� l ! 16.INNER,CASING QR TUBING, eothermal closed-loo
2.Well Construction Permit#• " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Variance,etc.) ft ft. tn.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROU.T
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAI. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t -Oement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft, ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a lkable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. fL
❑Experimental Technology ❑Subsidence Control ft. fL
[]Geothermal(Closed Loop) ❑Tracer 20.:DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
� ft. fti O GtA
4.Date Well(s)Completed:Well ID# 14" 3 7_'VS� S ft. �f 2 ft f,B
5a.Well Location: 1 7 ft. � ft. 2e& o k
77
m p 4 1.y y h a/ AS-
Facility/Owner�Naam/e ) Facility ID#(if applicable) ft ft.
ft ft `
Physical Address,City,and Zip ft ft
a_- 21.'REMARKS •a 5 "4 r --"-' :: "
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: `}+t Skll'i i'
,! ✓L�GN/ V �Z�
6.Is(are)the well(s): giPTF-manent or ❑Temporary --
Signature of Certified Well Contractor Date
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 MNv-- 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: e/` 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7'-' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifdifferent(example-3(g200'and 2@100)
�- 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: rS (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: t5r (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Air
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,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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: �
13b.Disinfection type; HTH Amount: Z Z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018