GW1-2022-06540_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
FROM TO DESCRIPTION
Well Contractor Name / ?d;ft. tt
�wit. ycrz, it
NC Well Contractor Certification Number I5.`OUTER'GASINGs for.inulti cased wells':UR LINERS it a "licab7e ;
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft 6
Company Name If-3 ft m
�Yp /] 16:.INNERCASINGOR`.TUBING.-"eotherinal'closed�loo" ,* ,;'� "- -`- '
2.Well Construction Permit#: /) w FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft It. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: T7.;SCREEN v r
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) OKesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Ini ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft GawAW6end Poured
❑Monitoring ❑Recovery ft. 3o ft. Joe �.
Injection Well:
t ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.:SAND/GRA�!EL PACK ,ta' li
❑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:DitIL4TNG;tiOG'attach edditio'ual."sheets if;necess'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRn'TION(color,hardness,soil/rock a in size,etc)
ft ft dude 6wa�aX1
4.Date Well(s)Completed: 2. �3 �ei:well ID# 40 1ft. 3 A ft
5a.WellLocation: 3 ft' -SZ0 it Cr�
&S�/' <^�� ft. ft
Facility/O er Name��- Facility ID#(if applicable) ft. ft
Physical Address,City,and/Zip ft ft.
t 1� `��j1� / 017
County Parcel Identification No.(PIN) EL 14A&G"*A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s): @41"ermanent 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: Dyes or �lVo 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 I 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: 5'2_0 (R') 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@100D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in,) 24b.For Injection Wells: Copy to DWI;,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r 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 DWIt,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) 1 Method of test: � 7
q �
13b.Disinfection type: HTH Amount: ` Z • 7-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018