GW1-2022-08747_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
b I )/y e— 34.WATER ZUNES _ '
Well Contractor Name FROM TO DESCRIPTION
3 b ft. lc9p ft. f A'¢ i
l,ft. -2Z�ft W( -29C> f© 2-6s /6 A15
NC Well Contractor Certification Number i _,., e_
,15..0iJ7'ER;CASING;foi:mulh-csas eil wells)`Oti LINER''if a liable)
Barnette Well Drilling, Inc. FROM I TO DIAMETER I THICKNESS MATERIAL na
tt ft. in.
Company Name //''�� -A6::INN ER CA31NG,OR TUBING;"'eotfierm_al+closed3oo'
2.Well Construction Permit#: /'�` FROM TO DIAMETER HI TCIQVESS MATERIAL ~
List all applicable well construction permits(i.e.VIC,County,State, Variance,etc.) ft ft. in*
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN
FROM TO ttJ DIAMETER I SLOT SIZE . THICKNESS I MATERIAL
❑Agricultural ❑Munk' al/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ig;rCROtJT ,,
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. �O fL Cement/Sand Poured
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
143.SANDIGRA�?ELPACIZ rf;a 'licable> .,:.:; ;°, - . '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Cl Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20=ARIIsLING: OG attach addriional.stieets.if necessa_
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilfrock e, rain size,eta)
a ft ft ED!1 e 2 b—�o�
4.Date Well(s)Completed: 3 'Z"--Well ID# R **el_ L'f ff Y®
5a.Well Location: r'® ft S,ft 2-6 w--u t
Facility/Owner Name [� Facility ID#(if applicable) Jy-tt
ft. ft.
Physical Address,City, n and Zip
, ft
�p 5 6 ,v ,� 21:ttE14IAItIzs r. x
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '!y
(if well field,one IaUlong is sufficient) 22.Certification:
36_ S2s-�3 N 7R - q64 �� W
6.Is(are)the well(s): ",-,—,.anent 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 Pro 1 SA NCAC 02C.0100 or 1 SA 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: 2-8(D (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@100D
10.Static water level below top of casing: Z� (ft.)) Information 24a. For All Wells: Original form to.Division of Water Resources (DWR),
Infoation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level above casing,use
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.)
Program, 1636 MSC,Raleigh,NC127699-1636
12.Well construction method:Ai r 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 depart`went of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
�nn Permit Program, 1611 MSC,Raleigh;NC 27699-1611
13a.Yield(gpm) Method of test: ��6 C_!-S @b�
13b.Disinfection type: HTH Amount: 7-©
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018