GW1-2022-05971_Well Construction - GW1_20220617

••��L o v�. a iev ,a a�1�1 JtEUU10((iwq) For Internal Use Only:
1.Well Contractor Information:
` ,�� I 14.WATER ZONES ! ,
Well Contractor Name FROM TO DESCRIPTION
- A
i /I
2O it. /F r ft.
NC Well Contractor Certification Number T"
15.OUTER CASING for multi-cased wells OR LINER(if a ]icable
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MAT RIAL
A' rt 2 9 rL n �( ?
Company Name , lJ FJ✓ K
,(] 16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: �( FROM TO DIAMETER I Tnrck'vESS I MATERIAL
List all applicable well construction permits rl.e.UIC,Cotmv.State,Ybriance,etc.) ft fL in.
3.Well Use(check well use): ft ft in.
i
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public fL ft in.
❑Geothermal(Heating/Cooling Supply) nResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft Cement/Sand Poured
❑Monitoring ❑Recovery I ft ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
39.SAND/GRAVEL PACK tf a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier; FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control ft ft.
❑Geothermal(Closed Loop) ❑Tracer i 20.DRILLING-LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,s illrock e,grain size etc.)
4.Date Well(i)Completed: 6 _ Jc�"z Z.Well ID# I � �� ft. ft.
5a.Well Location: ft. $^if.
X/A-K lj2e-�rt 2,1 C" 2 Lrc�rt• 3`1t�5 rt. C
Facility/Owner Name Facility ID#(ifapplicable) it. rt
Physical Address,City,and Zip It. ft J PY
� A 1 P 1-1-1a l 21 REMARKS t Y 1
J
County Parcel Identification No.(PIN) 'v v:V'i P.rs7
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/IDng is sufficient) 22.Certification: ?�
6.Is(are)the weU(s):4!11 a manent or ❑Temporary Signatute of Certified Well Contractor Date
By signing this form,l hereby certiti,that the well(s)was(were)constructed in accordance with
7.1s this a repair to an existing well: ❑Yes or �U 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out lotown well construction in formation and exp/din the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on die 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 t GW-.I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: —7 ' (ft.)
For multiple,vells list all depths rfelifferent(example-3Q200'and 2Q100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: ; ( ) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I
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 Rota 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
L13a.
ATER SUPPLY WELLS ONLY: i 24d.For Water Wells producjn2 over 100.000 GP D:Copy to DWR.CCPCUA
`` ! Permit Program,1611 MSC,Raleigh,NC 27699-1611
eld(gpm) L71T'1� Methodoftest: 1,9,1�(.00A
sinfection type: H ` R Amount: 't�
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6 2018