GW1-2022-01255_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
�c-�.� ! C� `.i p� ' 1C WATER.ZONES-.'
FROM TO DESCRIPTION
Well Contractor Name 7 ft. yo 41
33 Z
2_'70 f" 2 5-0 'L 'e7-0-1
NC Well Contractor Certification Number '15.,O-UTERACASING for tntilti4asied wells)ORXINER,(i ip !I
Barnette Well Drilling, Inc. FROM I TO I DIAMETER n T_TMCK14ESS MATERIAL
Company Name ft- It- 6
'16.INNER CASINGORT ING,("eothermal�Elosed-kbo0).,,---
2.Well Construction Permit#: FROM TO DIAMETER TIUCKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 317.SCREEN FROM TO DIAMETER I I SLOT SIZE I THICKNESS
ClAgricultural DMunicipal/Public ft- it.
OGeothermal.(Heating/Cooling Supply) IlResidential Water Supply(single) ft. ft. in.
0 fndustrial/Commercial DResidential Water Supply(shared) j8.':GROUT,
11 Irrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft Ceowf�,96-FiRd- Poured
DMonitoring ORecovery ft.
-7p ,
Injection Well: it. ft.
0 Aquifer Recharge D Groundwater Remediation
7SANDIC 6RAVEL 1?ACK(it'i0plicibli)ClAquifer Storage and Recovery 13 Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage ft. ft.
0 Experimental Technology OSubsidence Control ft. It.
DGeothermal(Closed Loop) OTracer ZO DRILLING;LOG
OGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTIONI (color,hardness,soil/rack t"e,grain size,etc.)
4.Date Well(s)Completed: J4-/S-W Well u[)# 290,d3l It. ft. ee .1
5a.Well Location: 1 Z_ft. -fb % r.9 iv eA<ywA,
rebeeco-1 _?b 12OLO
Facility/Owner Name Facility D:)#(ifapplicable) it. 3 6�
5*.o k,;46 Ln we"
Physical Address,City,and Zip ft
7 `BAN
12 7029
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/min'utes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification: M el 17
7 N W
'R4214_4�
6.Is(are)the well(s): gPermanent or oTemporary Signaturi 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: 0Yes or &Wo 15A NCAC 02C.0100 or JSA lVCAC 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 qJ'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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).Y:ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft') Submit this GW-I within 30 days i of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
1C, — 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 i MSC,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: IC (in.) 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
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where—installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producini over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NU 27699-1611
13a.Yield(gpm) Method of test: A'A aj­
13b.Disinfection type: HTH Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018