GW1-2022-08329_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Well Contractor Name FROM TO DESCRIPTION
It. U 0 ft.
3 z ft. ft.
NC Well Contractor Certification Number '115.-.OUTERCASINGff6r.. Wti-ciieiawJAit)
"if6pq'MATERI1L
L
Barnette Well Drilling, Inc. FROM TO DIAMETER _�THICKNESS_
Company Name 7 9 ft- in. 2_2 I
46.,
.1 NG
2.Well Construction Permit#: ,9 FROM I TO I DIAMETER L TMCKNESS MATERIAL
7—^
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:
FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal/Public ft.
ft. in-
oGeothermal(Heating/Cooling Supply) ORtsi'dential Water Supply(single) ft. ft. in•
01ndustrial/Commercial CResidential Water Supply(shared)
48AMOUT
01rrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- Geme 4, 46ard Poured
DMonitoring DRecovery ft -3o '- OC-4r.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[]Aquifer Test OStormwater Drainage ft. ft.
DExperimental Technology 0 Subsidence Control ft. fl-
LIGeothermal(Closed Loop) OTracer
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks)J FROM ft. TO DESCRIPTION(color,hardness,soillrock type, in size,etc.)
10 6_ ft 6 U e- P-AcK/
4.Date Well(s)Completed: Z—2-2- Well ID# ? ft ft AtS
5a.Well Location:
a fig Au d a,10 *7cA--g E&a,I fIL 6 Z .12
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address,City,and/Zip
_1111A
A)U
County Parcel Identification No.(PIN) APR I
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
2 N 7 e- W
6.Is(are)the welt(s): Mrmanent or OTemporary 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: OYes or MW 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
or 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-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: 2- 4) -(ft Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
10.Static water level below top of casing: (ft 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Ijwarer level is above casing,use"+"� Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+" i
11.Borehole diameter: (in.) 24b.For Injection Wells: Copy to
p DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC i 27699-1636
12.Well construction method:Air Rotary 24c.For Water Supply and Open=Loop Geothermal Return Welts:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Welts producing!over 100,000 GPD: Copy to DWR,CCPCUA
IC/16 Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gp-) Method of test:
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018