GW1-2022-06538_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information: {
Rn l�j t 13i'WATER Z01VES.s �,.
Well Contractor Name/' FROM TO l DESCRIPTION
NC Well Contractor Certification Number
I5.<OUTER CASiNG-for roulh-ca'se�'�vells`QRT.'IIVE.it(if a''lica'b'le
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAI Y?4
O ft. 1Z fL fj in. s 2 7 L
Company Name
.:16.INNER"S►NGORs`TUBING•.(:�i thermal_'-closed.)lou`..
2.Well Construction Permit#: D / '7 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. IL in.
3.Well Use(check well use): ft ft in.
Water Supply Well: = _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. ft- Gamail VS d Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
0,.SA'ND/GRAt EL PACIZ d.a iicdble ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control fL ft.
❑Geothermal(Closed Loop) ❑Tracer 20r.DRILLING f OG'ittacfi idditioYtii Stieets`.if necessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM fL TO fL DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed: S 'Z��'ell ID# 01 t-7 a�- ft. Z Zit eA CAI
5a.Well Location:
2 2 ft. j1� ft. a
A /ae I D9/�ley /l rt �0o ft aes
Facility/Owner Name / t Facility ID#(if applicable) ft it.
ft. IL
Physical Address,City,and Zip 7 ft. ft. "
! V 2 REMARKS,,:: t ,-
1. r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i-,v,A i rrt r!r r6C ES '•
(if well field,one lat/longS is sufficient) y 22.Certification:
6• T'9 s7` 7 N 7 • %Go / 1 WC�?/V1 l t�i• -,/pc'AC� 3 Z "�-Z
6.Is(are)the well(s): rmanent or ❑Temporary Signature of Certifiedell 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 2W I SA 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 oj'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: (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3 00'and 2®100D
10.Static water level below top of casing: �/.S� (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
op 7 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 DWI,Underground Injection Control(RUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and OpenLoop 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
13a.Yield(gpm)
!! Method of test: o`6Vt/'ta Permit Program,1611 MSC,Raleigh,'NC 27699-1611
' tx
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