GW1-2022-05803_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.We 1 Contractor Information:
P
Q� 14.WATER ZONES
_Well Contractor Name FROM TO DESCRIPTION
3`3�V = 5 ft. 5-5 ft. — L' I
NC Well Contractor Certification Number 15.OUTER
CASING(for multi-case .wells OR'LINER(Sf a IiMabAleE)
RIALTO DIAMETER T NBarnette Well Drilling, Inc.
0 ft. 12 0 ft / N S D12-2-1 PU C_
Company Name
a / 16.INNER CASING OR.TU;OING;, eothermal closed-too ,
2.Well Construction Permit#: I �b' FROM TO DIAMETER in.
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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) Lkesidential 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: O ft. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLAC&MEINT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG attach additional.sheets if necessary)
El Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
! D ft- :Z ft Vv2f7+�C^
4.Date Well(s)Completed: 02`- �Z Well ID# 1 I 2 ft. aG ft. W r�-
5a.Well Location: 6 ft. 65 ft. EJ roy-
N'dd SJ^S S ft. - .20 fL (r(b rt 2 X*z
Facility/Owner Name y� i Facility ID t
`#(ifapplicable) ft. f
J 5 C/ 1-d 1`1 r7 l A l lUtnG�\ ft. ft
Physical Address,City,and Zip ft. ft.
0 r 2 21..REMARKS 9N fin.,
County Parcel Identification No.(PIN)
202?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tfwell field,one lat/lon is sufficient)
22.Certification:
�v • � Z N / d z Z / J W /f r, , � ` t'a2'l''�'� ' 1 l' 11 G
6.Is(are)the well(s)° Wermanent 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 19No I5A 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:
8.7or 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
2
9.Total well depth below land surface: J 2 o (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
if Static water level below top of casing: Z (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+II" °
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,directpusb 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
13a.Yield(gpm) '5__ Method of test:8 low�t� Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HT'u Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018