GW1-2022-01257_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Vontractor Information:
iq- 101
14:°WATE20NES'
Well Contractor Name FROM R`TO DESCRIPTION
� yy)ft. oaf ft ,�...
w ft. ft.
NC Well Contractor Certification Number
Inc. '35:OUTERCASING for...iii lti cased wells ORLINER'f—ap licible
Barnette Well Drilling, c FROM TO DIAMETER I THICKNESSI N6URIAL.
Company Name
ft �L ft 6T in. � lf L
d �16. NER CASING'OR'TUBINGI i&Ni!i'mal elosed-too , •,
2.Well Construction Permit#: to �-` o FROM TO I DIAMETER ITHICKNESSI MATERIAL.
List all applicable well construction permits(i.e.UIC,County State,Variance•etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: .17.-SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
[]Agricultural ❑Municipal/Public tt ft in.
❑Geothermal(Heating/Cooling Supply) IJResidential Water Supply(single) ft ft in.
❑hmdustriaUCotnnmercial ❑Residential Water Supply(shared)
JI8XRouT._
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ('j ft Cemeht/Sand Poured
❑Monitoring ❑Recovery ft fL
Injection Well:
ft ft.
❑Aquifer Recharge []Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salim Barrier �"19.:SAND/GRAVEL-PACK:tf a 'licable
Salinity FROM I TO MATERIAL I EMPLACEMENT METHOD M
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer ?20:?DRII LI1VGrIOG aitac6 sdditioual sheets;if;riecessa' r.--
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock `e, in size,etc.)
ft. Lti ft n
4.Date Well(s)Completed: ! Z Well W# ft. ,(] ft
S'e d 4�C!
Sa.Well Location: Ct? ft
c '� ., C�1 I �� �� 9� ft. I t?'W ft .-
Facility/fOwner N me ] Facility ID#(if applicable) ft ft
ft. fL
Physical Address,City,and Zip C �( � ft fL
21'-REMARKS
:.r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) grtr l4;•p _
p C 22.Certificati'
L �r
6.Is(are)the well(s): l�Permanent or ❑Temporary Sign re of ertified a Contractor Dace
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 IiNo I5A 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 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: /
For multiple wells list all depths if different(example-3©200'and 2®100') ( ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: s (ft.) 24a. For All Wells: Original form to.Division of Water Resources (DWR),
If water level is above casing,use"jj+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(TUC)
Air Rotary
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method, ' 7 24c.For Water Supply and Open-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 producinRf lover 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) s�fd'` Method of test: �f Permit Program,1611 MSC,Raleigh,NC 27699-1611
t1
13b.Disinfection type: HTH Amount: 1/2 Cup
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018