GW1-2022-05973_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Info ation:
14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
r, lD ft. 1 9-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(ita licable
Barnette Well Drilling, Inc. FROM TO DIAMETER THIC/�KNESS MATERIAL
Company Name . O ft. ft 1'1 in. SP/`-Z'
//j^ /J fin/ P�./]// U 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: /Ifl •" 'N' ^/'q v( _ ��/ FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): fIt ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public >_ ft. ft. in.
❑Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) rt. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft- Cement/Sand Poured
❑Monitoring ❑Recovery tt. It. �6
Injection Well: to
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwatet Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional,sheets if necessary)'
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,eta)
ft. '2-- IL /
4.Date Well(s)Completed:ti-G.3- Well ID# 57 ft' S It- BW 0 J,-
5a.Well Location: 157 ft, Aqo fL 0 I(
ft. ft. �
Facilit/Own Name Facility ID#(if applicable) ft. ft. a
I10-!I' e ft. ft. JUN 17
Ph y ical Address,C' ,and Zip ft. ft. F
21.REMARKS ,- :dr;; ._•
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,C fi tion-
3 ° ��. ( USN 7 0 7- 6a�S W
6.Is(are)the well(s): ClPermanent or ❑Temporary Signature of Certified Well Contractor ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance will:
7.Is this a repair to an existing well: ❑Yes or ItNo 15A 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 I 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: (fk) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd(�erent(example-3@200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7`r (ft-) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: C 1' t,l (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: rr 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) ( S Method of test' 6Q M!n I Permit Program,1611 MSC,Raleigh,NC 27699-1611
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