GW1-2022-08336_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW 1) �
For Internal Use Only.
L Well Contractor Information: j
14..WATERZ9NES
Well Contractor Name FROM I TO DESCRIPTION
3 3 7 2i� ft ft Z 1
ft.
NC Well Contractor Certification Number ft 6 el
:15:iUUTER`CASING•for mulfl4 '' d wells Of LINER;Ma liable)
Barnette Well Drilling, Inc. FROM TO D1AME1'ER THICKNESS MATERIAL
Company Name 0 ft. 6 it in. S Z, pvC
pp 1 ) ,,I&INNfR•CASING It.: ING" eotherinal ddsed?loo . 0
2.Well Construction Permit#• � $' FROM ETER TO DIAM THICKNESS MATERIAL
List all applicable well construction permits#.e.UIC,Countv,State, Variance,etc. 7 Ij in.
3.Well Use(check well use): ft ft in. 4
Water Supply Well: 17:;SCREEN.
❑A Cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Muniaipal/Public ft. ft in.
❑Geothermal(Heating(Cooling Supply) InResidential Water Supply(single)
ft. It. in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AAfOIPVT
Non-Water Supply Well: ft ft nemenygand Poured
❑Monitoring it-
Injection Well: ft. �IS__ vt
❑A uifer Rec ft ft
q harge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier 19;SAND/GRA UELPACK,rFa licable
�' FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLIN_CILOG attach DE8C onsl;sheets if necess
FROM TO
❑Geothermal(Ileating/Cooling Return) []Other(explain under#21 Remarks) HIPTION(color,hardness,soillrock a in size,etc)
d ft //ft4?2 bcti4
4.Date Well(s)Completed ft ,oft
PA r
5a.Well Location: a / ft it.
C lAk?K iC. f1�L i,{?�S ft. ft
Facility/Owner Name AAFacility ID#(if applicable) ft. it.
.� I�/�l fp/�e bt ft ft r: T
Physical Address,City,and Zip ft R.
0 1?IQ r >j p 1 8'7 REMARICS. APR, t
County e� G. Parcel Identification No.(PIN)
4c IUrJ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: v1, y r-ter c^r
(if well field,one lat/long is sufficient) 22.Certification: y
5 5��_S—� N �2 /J.9 e3 I? W
6.Is(are)the well(s): Mermanent or ❑Temporary Signature of Certified Well Contractor Date
Bysigning thisform,!hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 1S.4 NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ofthis 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: -3_d&)
For multiple wells list all depths ifdifferenr(example-3@200'and 2@100) (f t) Submit this GW-1 within 30 days,of well completion per the following:
10.Static water level below top of casing: j O 24a. For All Wells: Original foim to.Division of Water Resources (DWR),
If water level is above casing,use ,+,, Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Rotary Program,1636 MSC,Raleigh,NC 2
12.Well construction method: 'Rotary Program,
(i.e.auger,rotary,cable,daectpush etc.) 24c.For Water Supply and Open(Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Over 100 000 GPD Co D i Method of test: d Permit Pro—gram,1611 MSC Raleigh,NC 27613a.Yield(gpm) S99-1611 py to CCPCUA
ti
13b.Disinfection type: HTH Amount �l, r `Zl g©�
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources f Revised 6 6-201 R