GW1-2022-05976_Well Construction - GW1_20220617

WEItI,CONSTRUCTI0N RECORD (GW 11 For Internal Use Only:
I.Well Contractor Information:
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3 f 76 _ >deft. , e3 ft. "a r
NC Well Contactor Certification Number f t `e?LSD ft
15.OUTER CASING for multi cased wells OR LINER if a livable)
Barnette Well Drilling, Inc. FROM TO DIA1�IETER THICKNESs MATERIAL
Company Name V ft-
6 3 ft. 1o2arin. I e
I,- gI A�C
16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: G j FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits�.e.UIC,County,State,Variance,etc.) ft. ft in.
JC
3.Well Use(check well use): ft. I ft, in.
Water Supply Well: 17.SCREEN
❑Agricultural FROM TO DIAMETER SLOT S)ZE THICKNESS MATERIAL.
❑MunicipaUPtblic ft. ft. in.
❑Geothermal.(Heating/Cooling Supply) P1Residential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18.GROUT
❑In'i ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: ft It
❑Monitoring ❑Recove 3® Cement/Sand Poured
ry, ft. fL
Injection Well:
❑A uifer Recharge ftii
ft
q g ❑Groundwater Remediation
[]Aquifer Storage and Recovery1 if a liable
❑Salinity Barrier FMATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 2G.(attach.additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1
FROM TO DESCRIPTION(color,hardness,sofur•ock type,grain size,etc.)
46 ft. T fG
4.Date Well(s)Completed: �" ell ID# (mil ft• / ft.
Sa.Well Location: ft. _
Facility/Owner Name n / Facility ID#(if applicable) ft. ft.
J � �C.R,��1 �f�� ' It. fL �
Physical Address,,/City,and Zip I / _
�I�elSO� -5' 1� 21.RENIARICS ez.
County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) ,F i;,."T"r,
p� G,� 22.Certification:
-74- 2Jy2.9 Z N J �`7'Z��?
6.Is(are)the well(s): et�rmanent 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repau•,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: I
i 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: [ (ft.)
For multiple wells list all depths ifdgerent(example-3@200'and 2(g100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7ir- (ft) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use""+'" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: b (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
12.Well construction method:Air Rotary
/� Program,1636 MSC,Raleigh,NC 27699-1636
(Le.auger,rotary,cable,direetpush,etc.) 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producim over 100 000 GPD• Co D
13a.Yield m A/0 Perm it ra
�P ) Method of test:
Progm, 1611 MSC,Raleigh,NC 27699-1611 Copy to CCPCUA
410
13b.Disinfection type: HTH Amount: Cup e
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Rr-viand t;-e-,)n 12