GW1-2022-07319_Well Construction - GW1_20220809

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WELL CONSTRUCTION RECORD(GW-1), For Internal Use Only:
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1.Well Contractor Innfformation:
�-J' Y_• �! j 14.WATER ZONES !
Well Contractor Name FROM TO I DESCRIPTION
;7 1 y .5-& 'A (
tS,j It. j q',,ft `0j�:-1( z.oe
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LlNERAfap liable)
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Barnette Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
V ft. eft in. -r&&,,z CJ�-
Company Name
�] O 16.INNER CASING OR TUBING("eothermal closed-loo
2.Well Construction Permit#• �/✓ j� FROM TO I DIAMETER THICffiVESS MATERIAL
List all applicable well construction permits fl.e.UIC,Countv,State,Variance,etc.) ft. It. 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
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lzri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL tt. Ga.,., d Poured
❑Monitoring ❑Recovery ft. ges R. Petis
Injection Well:
ft. tt
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a liable)
❑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 necessary)
FROM TO DESCRIPTION(color,hardness,soiltrack e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft ft C) at Sat-)
L`! ✓ � ft. ft.
4.Date Well(s)Completed: a4Vell1D#
5a.Well Location: eft ft wii., �Ic
mot' 2- a Kr2 b
Facility/Owner Nam Facility ID#(if applicable) ft. ft. !o S
` ft ft G e 9 P
Physical Address,City,and Zip ft. ft. AUG
r Q 2022
IC..?1,P ,uj 21.REMARKS
County Parcel Identification No.(PIN) lC' ` J ^V �nq UDIt
✓.. rt5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,oneladlDng is sufficient) �} g 22.Certification:
-3 6 -J01 r3 N '7d (J d 346f W r-
is-�n��� &- -� 6-� Y-2 z
6.Is(are)the well(s): 9'Pefmanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certifv that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO r 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out!mown 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 l 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 dierent(example-3Q200'and 2@1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: �� (fL) 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 DWR,Underground hijection 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
13a.Yield(gpm) Method of test��lg�� 17
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HT Amount: p / 0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018