GW1-2022-08355_Well Construction - GW1_20220418

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
a �
to--&t 46.e E s u.1 14s WATER ZONES ;. ..v
Well Contractor Name FROM TO DESCRIPTION
ft. i
NC Well Contractor Certification Number a5.'OUTER'CA$lNG'for;multi case8 wetis':�RtLINER tf a `"livable
FROM TO DIAMETER THICKNESS MATERIAL
� rt.
Barnette Well Drilling[ Inc. 2 ft.
Company Name
;J6:INNER CASING OR TUBING, eothermal closed f'oo r
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(r.e.UIC,County,State,Variance,etc.) ft. ft. 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) 19Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. l:ome49ReM Poured
❑Monitoring ❑Recovery a ft. 20 ft. Aep,,14 c
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
D.SAND7GRAYEL PA'CIC
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology El Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .�20:DRILLING I:OG attach addi(inoai,stieets2f Aeeessa`.
FROM TO DESCRIPTION(color,hardness,soil/rock e, rain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
ft. � fw Q ♦r YJZ9- ® Eft
4.Date Wells)Completed:
22 r2 2 Well ID# ft. it ke-L C l
5a.Well Location: 0 ft- Y/t'S fw /L S ?R i rt+�e_
P A KTft .V-k ft. (5' . ►'4 G�
FacilityOwnere Name
/- Facility ID#(if applicable) ft. ft.
ft. ft.
Physical Address, and Zip ft. ft. r :�U V4
Z AP y -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification
�6 4`z3 }z N WL�--r-� e,
6.Is(are)the well(s): ermanent or ❑Temporary Si titre 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: ❑Yes or LWo 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 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: �y 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: `7`� (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@I00)
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: e,�C7 (ft.) Information Processing Unit,1617MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: (7 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC i 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: Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018