GW1-2022-05797_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ontractor Informs
;f s, e f UA 14.WATER ZONES
Well Contractor Nyameee FROM ft. TO DESCRIPTION
9 ft- 2 X rt.
NC Well Contractor Certification Number G
15.OUTER CASING for multimeasedwells).QRLINER it.a' livable)
Barnette Well Drilling, Inc. o�= TO D ETER THICICNES ERIAL
Company Name
16:INNER:GASING:OR:TUBING( eothermalclosed-loo
2.Well Construction Permit#: FROM TO .DIAMETER THICKNESS MATERL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. in. IA
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) CJResidential 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: ft. Zv ft. Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation
348ANDlGRAVEL-PACK.if a livable)'..
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Ex erimental Technology El Subsidence Control ft. ft.
P gY
❑Geothermal(Closed Loop) ❑Tracer 2Q.;DRILLING LOG attach additional.sheets:if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ft 2- ft v e t-/ a dt ,
4.Date Well(s)Completed: Well ID# 5 7y 6'?Y 7o ft. ft
Sa.Well Location: ` ft. gei"t
ft. ft. f� r
Ewl
Facility/Owne`rrName Facility ID#(if applicable) ft. ft. } pl
�T 6®� t " ft. ft
Physical Address,City,and Zip
'21.REMARKs
u•
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fielto one l t(longiisLsufficient) a `�J 22.VCer�t�ffi�con:
6.Is(are)the well(s): ? ermanent or []Temporaryatu a UCe ifiea ell Contractor Da
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 J(No ISA NCAC 02C.0100 or ISA 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: ZA (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: / 6/ (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,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: HT'H Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018