GW1-2022-06001_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD.(GW-1) For Internal Use Only:
1.Well Contractor Information:
r .14.-WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. �7 ft.
NC Well Contractor Certification Number 15..OUTER CASING for mdlti-cased'wells OR LINER(if'a 'licable)
Barnette Well Drilling, Inc. �oM TO DIAMETER THICKNESS MATERIAL
Company Name �4 ft. 4 O ft. in. s � l U�
/ ,J6vINNER;CASING OR-TUBING. eothermal closed-166
Z.Well Construction Permit#: \ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.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 TMCKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18::GROUT -
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D fI- _ Z fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.,SANDIGRAVEL PACK(if.applicable .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ca2,0 PRILLING LOG attach,additional;sheits if neces§a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
4.Date Well(s)Completed: 6�— Well ID# G/9 Y �C� ft. �7z ft ,eZI S6 r'-'
5a.Well Location: ,l ft. ft. S- ��
ft
ft. ft. �'` 4.I•s'T I
Facility/Owner Name Facility ID#(if applicable)
Pl-I 1 = '�� ,ce �D ft. ft. � '7J� i •
Physical Address,City,and Zip ft.
21.REMARKS - ,,.,,,,FC,• _, ..- - •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well/field,one IaNlong is sufficient) Q 22.Certification:
6.IS(are)the well(s)-I�Permanent 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
�lAf6
7.Is this a repair to an existing well: Dyes or 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 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: -7 b (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(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: Z (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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) � Method of test: � E
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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