GW1-2022-08353_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
14-WATER ZONES :1
Well Contractor Nam Je FROM TO DESCRIPTION .
NC Well Contractor Certification Number
15.ibUTER CASING(for wells UR I:INERi((f a"livable) = '• ';
Barnette Well Drilling Inc. FROM TO DIAMETER THICKNESS MATERIAL
a ft. ©ft. / f in. s3,A.2
Company Name V
�� :],6ANNER'CASING 0114 B7NG eothermal dosed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ft ft. in.
3.Well Use(check well use): fL ft in.
Water Supply Well: 47.SCREEN• >.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in.
❑Tndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT• t'z
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL y EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft nd Poured
❑Monitoring ❑Recovery ft. ��ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19::SAND/GRAVEL PACK ifa` licatile _
❑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.DRIL-LING'LOG:attach eddiflonal,sheetsif necess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soft/.&type, in size,etc.)
e. ft
4.Date Well(s)Completed: ` K ID#_?K G S Z-? ft*
ft t
5a.Well Location: 2— tt. 2 ft D wj- -S 1 S h
ft. 36Gft C 'C�
Facility/Owner Name Facility ID#(if applicable) fL ft.
9 3 6 S— A ft ft
Physical Address,City,and
/Zip ft ft.
fJ �Oy 3L:'REMARKS':. f
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: APR 18 2022
(if well field,one lat/long is sufficient) 22.Certification:
6 - T6 7T N 7d 77 Z / W A�`�°� r � 'IZ
its Ctul: fi r'L,
6.Is(are)the well(s)• MPermanent 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: ❑Yes or LtlNi— 15A NCAC 01C.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: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t, (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if difj'erent(example-3Q200'and 2®100�
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617;MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
i
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
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: Permit Program, 1611 MSC,Raleigh;NC 27699-1611
T/ !�-
13b.Disinfection type: HTH Amount: �.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018