GW1-2022-01252_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