GW1-2022-01267_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
A l/4'2V 14.WATER ZONES �
Well Contractor Name FROM I DESCRIPTION
ft. ft. E
NC Well Contractor Certification Number
15.LOUTEWCASING for tnultI-cased wells'ORLINER_if a "Gcable'
Barnette Well Drilling, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft.
Company Name !
16.:7NNER CASING OR TUBING clased-16661
2.Well Construction Permit#: 1 "- "7 Z FROM TO DIAMETER F THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. It. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. g• in.
❑Geothermal(Heating/Cooling Supply) L9itesidential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.-GROUT
❑hTi ation ❑Wells>100,000GPD FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft- Gefflelat4md Poured
❑Monitoring ❑Recovery Q ft }D ftY �
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation [t. ft
❑Aquifer Storage and Recovery ❑Salmi Barrier 19..SAND/GRAVEL PACK ifa applicable)
tY FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft ft
❑Geothermal(Closed Loop) ❑Tracer 20.<DRiLLING-LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soil/rock e, in size,etc.)
4.Date Wells)Completed:l 2"Z -z-1 Well ID# W l-Q3'?L ft. ��'ft -$,a t
5a.Well Location: s ft. OF iL
Facility/Owner l me Facility ID#(if applicable) ft. ft.
'7 q 0 -4 /�n>, �2�> V S r f�`+7o-t-¢: - ft ft.
Physical Address,City,and Zip ft. I ft.
le�i2�1 ,I�r_3 6 3 �O`t 5_ 21,,REMARKS -.,. "?I`. 7, � T,�
1, _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ?Un
Z�
(if well field,one lat(long is sufficient) 22.Certification:
D3 � 3A!'.' N _ ? � O � 2 dd
O� W 'I ;-
1 .2_f/�� �Z"_Z Z
6.Is(are)the well(s): INifirmanent 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 JTWo ISA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis 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 thisform.
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: 6 0 O (ft.)For multiple wells list all depths if different(example-3@200'and 2@I001 Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original!form to.Division of Water Resources (DWR),
If Static water level below top of casing:__ �.� (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617 If water level is above casing,use"+" g g
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Air Rota
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 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 producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
ale aj Pemut Program, 1611 MSC,Raleigh,NC 27699-1611
u u
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13b.Disinfection type: HTH Amount:
t
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised&6-70 1 R