GW1-2022-08365_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contrrac1toor,`InforrJmatioon: FROM TO DESCRIPTION
Well Contractor Name .
O A7
NC Well Contractor Certification Number
,15.OUTER'CASING'fo,B:muitiras'ed webs bT21:INERf if a`"'livable). s'"
Barnette Well Drilling, Inc. FROM I TO DIAMETER THICKNESS N&WIAT
ft. 4� ft. 6� in. S� z
Company Name
76.INNERGASINGORTUBL�IG="eoihcrmalclosed=liie`
2.Well Construction Permit#: �t FROM I TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft ft in.
3.Well Use(check well use): ft' fL in.
717.8CREEN_',;
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipai/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) SR15i'dential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 48;,GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Poured
❑Monitoring ❑Recovery 0 ft 7-5-ft
Injection Well:
ft ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL"PACK if Ap livable
❑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 additio'iiid sheetsiif necess' ._[typ 'a
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocke, in size etc.)ft.
ft ft
/9 /U 4- '4.Date Wells)Completed: �Z Well ID# ft. ft � f
Sa.Well Location: n J`t c,
CAM�/L© UC Cam® `" ® ft Sao
Facility/Owner Name Facility ID#(if applicable) ft.
ee C, ft Gam ft la.
Physic 1 Address,City,
and
Zip
ift Qr� ��® ;;21.;REMARKS'�;: ..'.-'. ..:• `' :.. � ,.
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.Is(are)the well(s): Mfermanent� 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 L'3I'd'— 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: 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 diferent(example-3@200'and 2@I00D
24a. For All Wells: Original form to.Division of Water Resources (DWR),
10.Static water level below top of casing: Z 6— (ft.) Information Processing Unit,1617IMSC,Raleigh,NC 27699-1617
If water level is above casing,use
24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method:AI r Rotary 24c.For Water Supply and Operi-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 Prod ucint over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test: �l©4A-)
13b.Disinfection type: HTH Amount:-R�' i e- z
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018