GW1-2022-06007_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
14.:WATER ZONES
4 "yL r'1 Y/ln I
We1lContractorName FROM TO DESCRIPTION
ft. Zcd ft. L
ft. ft
NC Well Contractor Certification Number
15.OUTEA CASING(for multi-cased wells).,ORrLINEIt"(if a' Iicable)
Barnette Well Drilling, Inc. FROM T��f
DIAMETER THICKNESS MATERIAL
o ft. in. Q2E_oC 1 �fL
Company Name s
16.INNE]3;GASINGOR;TUBIN eothermalclosed-loo
2.Well Construction Permit#: `I S FROM TO DIAMETER TMCKNESS 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 DIA ETER 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 -
❑hrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0. ft 0 ft Cement/Sand Poured
❑Monitoring ❑Recovery ft ft
Injection Well:
ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19..SAND/GRAVEL PACK ifa "licAble
❑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 20.DRILLING LOG attach.additional"sheets if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Qft. 2 ft. r�Dt I
4.Date Well(s)Completed: -ZZ Well ID# 7I O� 2ft. ft
5a.Well Location: ft ft. �e7 f p
/VS ft 1q0 It
Faciillirty/Owner Name'
I Facility ID#(if applicable) ft. ft y
(le�sc� � /�( fL ft �' <*-F ��4
hP ysica
Pe.(
all Address,City,and Zip ft ft.
Pe. �D n 21.REb1ARKS
County Parcel Identification No.(PIN) "' a•&^7^.`d
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Zecation:
SiJ646
6.Is(are)the well(s): OPermanent or ❑Temporary of Certified Well Contractor D to
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 ±No 15A NCAC 02C.0100 or ISA 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-I 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: Ll (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if dierent(example-3@206'and 2@1000
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (fo Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
/ 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: � � (in.) 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
(Le.auger,rotary,cable,directpush,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
Q010 Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: HTH Amount: 1/2 C u p
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018