GW1-2022-05977_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. 11. A-
ft- It-
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable)
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESs MATERIAL.
, in. � ��
Company Name
16ANNER CASING OR TUBING-( eothermal closed-loop)
2.Well Construction Permit#. FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC County,State,Variance,etc.) IL 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) MResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL E_3M LACEMENTMETHOD
❑Aquifer Test ❑Stormwater 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) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type.Crain size,etc.)
ft.
4.Date Well(s)Completed: 2 Well ID# t
1" i 2- ft'
5a.Well Location: k2_ ft. 36-- ft. * I'
L Y�V 5
j'ft. 1g e1®ft.
Facility/Owner Name Facility ID#(if applicable) ft.
Physical Address,City,and Zip ft. ft.
21.REMARKS jUN '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
..rvinvrni��
(if well field,one lattlong is sufficient) p q 22.Certification:
3 N CD W C
6.Is(are)the well(s)• &.1'rmanent or ❑Temporary Signature of Certified well Contractorly Date
By signing this form,I hereby certifv that the well(#)was(were)constructed in accordance with
7.Is this a repair to an existing well: Dyes or CI'K0 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 ouorer.
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 ifdi,Jferent(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: 2� (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use•'+"
11.Borehole diameter: 0/ (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 Droducine over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
u u s�C
13b.Disinfection type: HTH Amount: f ee O e--
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018