GW1-2022-05967_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name �/� •? _
J1JC> ft. ft _ ' _
NC Well Contractor Certification Number .15;OUTER CASING for multi cased wells OR LINER(if a livable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name Q ft. ft G j'� jc jZZ �tr
16ANNER CASING OR TUBINGIkiothermat closed400 )
2.Well Construction Permit 7q FROM TO DL4METER THICKNESS MATERIAL
List all applicable well construction permits(i e.UIC,County,State, Variance,etc.) C) .ft. ft [G in, ✓r 2 r
3.Well Use(check well use): ft. ft. (t in• �, �� ,(
Water Supply Well: 17.SCREEN'
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERLAL
❑Agricultural ❑Municipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Lo It Calent/%aad Poured
[]Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
..19..SAND/GRAVEL PACK.if.a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.,DRILLING;LOG;attach•additioual sheets.ifnecessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc.)~
1 6 ft. tS— ft. U L' 6/&1
4.Date Well(s)Completed: ID# ^ 7 It. g ft. �G`� I/i �• I
5a.Well Location: ft. Sa It.
1�/�P�� ���N �t: g���•� 5 It.
�� ft
Facility/Owner ame Facility ID#(if applicable) ft.
ft. ft
Physical Address,Ci ,�anfd Zip Cy ft. ft 9
t �IL.�6 �tJ G / 21.REMARKS .
County Parcel Identification No.(PIN) �• .. `
IF
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f' -.;' it;F� ''•)
(ifwell field,one lat/long is sufficient) p 22.Certification:
6.Is(are)the well(s)• AWEffii anent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ANr - 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: !7 (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@I00�
-�� 24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater 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
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
j ` Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) /��t Method of test: � ®Ll�
13b.Disinfection type: H I-t-L1 H Amount:Weap
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2019
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