GW1-2022-05972_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.WATER ZONES !
Well Contractor Name FROM TO DESCRIPTION
- ` ft. ft.
`�?
✓ 3 / �9 " ft. ft
i
NC Well Contractor Certification Number -15.OUTER CASING for multi cased wells OR.LINER-if h licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THIc N S MATERIAL
® ft. 7 ft [ in. >tZ�f
Company Name v
16.INNER,CASllYG-:ORTUBING 'eothermalclosed-foo ) .-
2.Well Construction Permit#: FROM To DIAMETER THICICN>SS MATERIAL
List all applicable well construction permits(1.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) nResidential Water Supply(single) tt ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 48;,GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Geff enYS—at-A Poured
❑Monitoring ❑Recovery ft, ft
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
,1$;SAND/QRAVEL•PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control ft. ft
❑Geothermal(Closed Loop) ❑Tracer 20..DRII LING LOG attach additional-slieetsA necessary)-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiUrack e, rain size,etc.)
tt ft. 7O S D'I
4.Date Well(s)Completed: -'3/-'-72 ID Wel1 # i �� 2- ft. Z� ft C
5a.Well Location: /rZ
� j3 l ft t�v ft-
Facility/Owner Napa Facility ID#(if applicable) ft ft. p
ft ft y :7§t;p?"
6/•T /�h-�9� /C�gB�� n/ it •a n'.' ..
Physical Address,City,and Zip
� ft ft. .._..._ _.
2L.REMARKS.. r
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: o,
(if well field,one lat/long is sufficient) 22.Certification:
36 334 N `2 `�- & W
6.Is(are)the well(s): tIlermanent 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 8wo— 15.4 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: 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: (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,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
13a.Yield(gpm) Method of test:
D d `�Q� Permit Program, 1611 MSC,Raleigh,NC 27699-1611
p/
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018