GW1-2022-05798_Well Construction - GW1_20220615

i I
WELL CONSTRUCTION RECORD (GW4) For Internal Use Only:
1.Well Contractor Information:
0.
�x �^Ay10 u s ,14.WATER ZONES
�' FROM TO DESCRIPTION
Well Contractor Name )
J 3 7 l ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for.mhlti cased wells)OR'LINER(ifa licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
61 ft. ft. j in.
Company Name CJ J C� Jzr�
16.INiNER,CASING OR TUBING'geothermal closed-loo
2.Well Construction Permit#: 3-z'r 7i FROM TO DL,METrR THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN -
Water Supply Well:
PP Y SIZE i` THICKNEss MATERAAI. �
FROM TO DIAMETER SLOT
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) C1Residential Water Supply(single) ft. 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: © ft. ft CemenVSand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND7GRAYEL`PACIC if a' licable' _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERUL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DRILLING LOG attach additional sheets if necessa
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Reinarks)J
FROM To DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
c ft. S ft d t/ 6 w2�Os�
4.Date Well(s)Completed: -aq 22Well ID# ? �- 7 7 2 � ft. j ft e& - c!) .
5a.Well Location; 2 ft. ft. j S.6
ea I La ,1 �1� 1��� ft. �C9 ft. _/9
Facility/Owner Name Facility ID#(if applicable) ft. ft. Q'9 p�g nq-
� ' Z �GLYYJ ic LA.igje it dkt' � ft. ft. g i =• C�i @
Physical Address,City,and Zip
ft. ft. 2022
l3 7� �✓a 1 21:REMARKS r 7
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:
36 � Z4/-6J> N `7F 675-15-k W
6.Is(are)the well(s)• M41 rmanent or ❑Temporary Signature ol Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 1??6- 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: �-s (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
W 12. ell 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
l dtest: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of
13b.Disinfection type: HT'H Amount: 75 c mz
h
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018