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HomeMy WebLinkAboutGW1-2022-01252_Well Construction - GW1_20220112 WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1.Well Contractor Information: 4 WATER'ZONES.-l', FROM TO DESCRIPTION Well Contractor Name ft. 3-?,7Z /4 2-0 ft. t36 IL —A Is NC Well Contractor Certification Number 15.OUTER CASING(f6rmtilti=Fzsed wells) L-INERTf lible) Barnette Well Drilling, Inc. FROM I TO I DIAMETER THICYLNESS MATERIAL 40 ft. Lt 6 ft. I 4- in. Company Name 6 16.INNER'CASING OR TUBING(eleother al,closed-loop) i 2.Well Construction Permit#: FROM TO . .DIAMETER I ER in. THICKNESS List all applicable well construction permits(i.e..UIC,County,State, Pariance,7tc-) ft ft 3.Well Use(check well use): in. 4 .SC ', Water Supply Well: F7ROREEN- M TO DIAMETER SLOT SUE I THICKNESS MATERIAL OAgricultural DMunicipal/Public ft. f, in. DGeothermal(Heating/Cooling Supply) (IResidential Water Supply(single) ft. ft. in, OEndustrial/Commercial OResidential Water Supply(shared) I8 GROUT 0 Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: ft. rL Cew*i8R=d Poured DMonitoring EIRccovery (r) ft. ft. Injection Well: 0 Aquifer Recharge D Groundwater Remediation 19;.SANTD/GRAVEL,PKCIC(iGaOOlieablel. OAquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD 0 Aquifer Test DStormwater Drainage ft. ft. oExperimental Technology D Subsidence Control ft. ft. oGeothermal(Closed Loop) CTracer 2 DRILLIN G;COG,(attach-Additi& OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)J FROM ft TO ft. DESCRIPTION(color,hardness,soiltrock type,grain size,etc.) 4.Date Well(s)Completed: we,,ID# / 2-2-7 ft. J ft 5 6 /4 ft 5a.Well Location: /FROM TO fftt' -2�0 dt' Y20 -10z�s, ft ft. fL Facility/Owner Name Facility ID#(if applicable) ft. ft. . 8 Yn") Hylt, Kik, J 6 IT47 ft ft. Physidl Address,City,and Zip fL ft. REMARKS JAM 11 V 0/ L VC(IlY JIS "4- '1 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: Y 6 N 72 - 1 .6-,L2- w k — 6.Is(are)the wells): anent or OTemporary Signature of Certified Well Contractor Date By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance with 7.Is this a repair to an existing well: Dyes or OD 15A 15A 1VCAC 02C.0100 or 15A 1VCAC 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. i 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 I 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: (ft.) Submit this GW-1 within 30 days of well completion per the following: For multiple wells list all depths if different(example-3@206'and 2@100') 24a. For All Wells: Original form to.Division of Water Resources (DWR), 10.Static water level below top of casing: Z (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+'* 24b.For Injection Wells: Copy ito DWR,Underground Injection Control(IUC) 11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC,27699-1636 12.Well construction method: Air Rotary 24c.For Water Supply and Open-Loop Geothermal Return Wells:C6py to the (i.e.auger,rotary,cable,directpush,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 5/69 0�; Permit Program, 1611 MSC,Raleigh,NC 27699-1611 13a.Yield(gpm) Method of test: 0 13b.Disinfection type: HTH Amount: J22-QffP 7 Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018